Coding Auditing/Validating CDI's Codes
Our coding team is working on auditing/validating the inpatient diagnosis and procedure codes that are coming to us from our concurrent CDI team review. We are interested in talking with anyone who may have already worked through and vetted this process. Can anyone comment on if your coders are using the CDI codes as a spring board and validating the diagnosis and/or procedure codes CDI has assigned? Or, are the coders starting fresh and recoding the account and then reconciling with what CDI has coded prior to billing?
Comments
Good Morning, Our practice has been that the coders start fresh. Clinical documentation nurses and coders each bring their expertise to the case which supports this process. If their is a mismatch after coding has completed the case, the documentation nurse and coder discuss the case and then escalate if needed.
My thoughts are that many (most) coding programs, and perhaps manyCDI teams as well, use coding software that ‘reads’ the chart and applies suggested coding. From my experience as both a coder and CDI professional, I use the draft codes suggested by the software, vetting and issuing a query as needed. I don’t think coding managers will turn off this feature and use the codes suggested by the CDI.
Paul Evans, RHIA, CCDS