No need for CDI?

katysuegood@gmail.com · February 2013

Hi all!

My director recently was tasked with being responsible for CDI at a small sister hospital of ours. HIM has been resistant to CDI in the past and seem to think that the coding dept is just as effective at clarifying documentation as a (potential) CDI program. I am wondering how some of the more experienced coders on here (and all others) would respond to this assertion.

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

cstukenberg · February 2013

I think one of the biggest advantages of CDI is the concurrent coding and documentation piece. This not only affects the timeliness of a complete chart, but also other disciplines such as case management with length of stay and the working DRG. It also affects those who look at Core measures to make sure those potential diagnosis are called out concurrently while the patient is still here.

donna.kent · February 2013

It seems to me that leaving this issue only in the bucket of coding deems CDI's relevance to merely a reimbursement issue. CDI is about a complete and accurate tool of communication regarding the patient's stay at the hospital. Involving dietary, pharmacy, nursing, laboratory and radiology to name a few goes a long way to achieving the goal. We understand that coders have productivity goals to achieve and most do not have extensive clinical background. That said, what they do is crucial to accurate coding but it is only one part of the TEAM for CDI.

Okay. I'll get off my soap box.

Donna

Donna Kent, RN, BSN,

evanspx@sutterhealth.org · February 2013

Concurrent review is better and more effective than the retrospective review typically conducted with HIM.

Concurrent CDI, when conducted by someone with the correct training and background (proven by achievement of CCDS?) is obviously more effective than a retrospective review.

I would only state, that apparently 'some' coders in some states (?) (non-credentialed) do not have an extensive clinical background?

At least, that is what is stated on the blog. Apparently, some sites must use coders that do not have a BS degree with formal clinical training)? The situation is far different in California as coders lacking credentials and clinical education are few?

I do not want to start ANOTHER chain about nursing V coding - but, do bear in mind that, just as with LVN, RN and RN with BS - the term 'coder' does not indicated the educational level of the 'coder', to include clinical courses.

Paul Evans, RHIA, CCS, CCS-P, CCDS

lprescott · February 2013

Donna, I am on the same soap box...I think there is room for both of us! To me the benefit is face to face....on sight....concurrent education to EVERYONE who is involved with documentation. Due to our teaching we have nurses, dieticians, respiratory therapists, physical therapists... who all now understand their assessments and good documentation can lead to the physicians documenting better. How many times have you heard an ancillairy staff member say.."Nobody reads my notes!". and I also find the physicians step up to the plate to document better by my being visible when they dictate. (Mommy's listening!).

CDI and concurrent chart reviews also can positively affect the billing cycle. if the chart goes to the coder with all queries asked and answered prior to discharge- the chart is coded - dropped and billed in a more timely manner. We have had a huge impact on the DNFB (discharged not final billed). Just today, I had a physician ask me to review his discharge summary because he knew the patient was going to be "high dollar" (long stay, high volume of tests and services) his thought was "tell me if anyting needs to be clarified now... so the coder can get the bill dropped."

Lastly, as a nurse I know I have been able to impact severity of illness and CMI greatly. The translator and on the spot education is priceless to the physcians.

Laurie L. Prescott RN, MSN, CCDS
lprescott@morehead.org

evanspx@sutterhealth.org · February 2013

Laurie: I agree with 100% and I would only state, that, as an RHIA, CCDS, (coder), I also know I have been able to impact severity of illness and CMI greatly. The translator and on the spot education is priceless to the physicians.

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

carmella.gay · February 2013

I have been coding for as long as I can remember and the impact CDI has on getting clarification on the chart before the coder looks at it makes a significant impact on the DNFB also. We have greatly reduced our post discharge queries and that reduces the time it takes to get the bill out the door.

Carmella

Unknown · February 2013

One point I would like to add is that while the record may be ready for coding with all the "CCs/MCCs in the documentation, often times the documentation supporting the clincial context of these "additional" diagnoses is not in the record. While we may be positively impacting CMI and DNFB, are we unnecessarily contributing to denials and recoupments downstream. Just some food for thought

cstukenberg · February 2013

I would caution querying for diagnosis just to capture cc/mcc but instead the accuracy of the record with supporting context.

lprescott · February 2013

We would not be doing our job correctly if we were querying for only cc-mcc and were not using clinical knowledge and indicators to support the queries.

Laurie L. Prescott RN, MSN, CCDS
lprescott@morehead.org

Unknown · February 2013

My perspective is that the coders seem to have a harder time getting a response and, at least here, the coding query is done after discharge thus needing an addendum to the record (and delayed billing). I think that draws red flags to potential auditors. Having CDI ask the query during the stay improves the documentation in real time and often there is more communication between CDI and physicians.

Linda Haynes, RHIT, CCDS | Manager, Clinical Documentation Improvement | Legacy Health
1919 NW Lovejoy | Portland, Oregon 97209 | 503-415-5609 | lhaynes@lhs.org

lprescott · February 2013

Paul- I agree as a coder you have as much impact as me the nurse. I think my experience and skills and yours' combined is what makes the best CDI program. We each bring different "skills" to the table but when combined we are very effective. When I started as a CDS, if it not for the coders teaching me I would never have been as successful. And I think that using my nursing and clinical knowledge, ease in communicating with medical specialities as also help them improve. I am a very strong believer that this requires coders, and nurses together working as a team. The programs I have spoken to that seem to have problems tend to not have a very good relationship between the two.

Laurie L Prescott RN, MSN, CCDS

evanspx@sutterhealth.org · February 2013

Laurie: Thank you for your response and I agree a symbiotic relationship is 'best'. I did want to state that my opinion, that "coders", too, can be effective serving as CDI reviews. It all depends upon the training, skills, education, and experience of the individual.

Paul

donna.kent · February 2013

I think either I overstated the case or just generally insulted some folks. That was not at all my intent. Where I work we have developed and work very hard to maintain a very healthy and respectful relationship with coding. We value this relationship immensely as do they.

Donna

Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com

redjay2 · February 2013

I have been doing CDI fo the last 5.5 yrs. It has to be Experienced nurses and coders . Working together as a team. We both learn from each other ...what's important ,how to clarify ,what to ask... Couldn't imagine not having a Coder with me .

Unknown · February 2013

Yes, I agree that retrospective queries throw up a red flag, particuarly in light of the fact the majority of Medicare contractors spell out that they will accept retrospective physician documentation in only limited circumstances. If one thinks about it, retrospective clinical queries are a direct measure of the evident deficiencies of a CDI program. Theoretically, there should be very little need for retro queries if the phycicians were sold on the value of CDI and were active participants in the program versus targets.

tpeyton · February 2013

I agree. I have been doing this for 5 years now....I have the most awesome coder....even though she codes remotely I can call her anytime and vice versa. We have both learned alot from each other. I can't imagine being a CDI and not having a good relationship with your coders.

Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406

fishdl@shands.ufl.edu · February 2013

Having built a strong CDI team consisting of both nurses and certified coders, including a certified coder who worked on the physician-side of coding/billing, I couldn't agree more! IMHO, CDI teams which include a variety of backgrounds and knowledge bases are much more effective and provide greater ROI to the organization.
Donna
Shands @ UF

katysuegood@gmail.com · February 2013

Thank you everyone, for your responses. I agree with you sentiments. For the first 1.5 yrs of my work as a CDI I spent probably a third of my time working side-by-side with our coding manager and have learned so very much from her and the rest of our coding staff. We both work remotely now but I still spend a few hours a week on the phone with her. The relationship is mutually beneficial as she also routinely reaches out for me with questions or for collaboration on projects.
I was tasked with making a PowerPoint for our Sr. Management team and wanted ONE slide included as to why CDI is needed on top of a HIM query process.
I am still working on the presentation but I attached what I have so far for that particular slide.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

sharon.cole · February 2013

Our CDI program has been in effect for 6-7 years now and there is still resistance from the coding department - which is why we are housed in case management. Our COO is very supportive though.

Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org

ddouthit · February 2013

As a coder and now a CDI specialist it saddens me that there is still a disconnect between some coding departments and CDI departments. A CDI specialist and coder can complement each other so well with the right attitude.

Dorie

angelisa.romanello · February 2013

When we first began, 5 years ago, the coders were afraid we would take their jobs. We worked hard to develop a collaborative effort. They now say that our queries on the front end assist them with their production on the back end. We are a very production oriented organization. Our CFO is so supportive.

Another point that may be helpful is the fact that our coders are off-site and we are here in the hospital. Many times just a conversation with the MD can lead to a more acceptable query response.
Just some thoughts. Good Luck

Lisa Romanello,RN,BSN,FNS,CCDS
Clinical Documenatation Improvement Specialist
CJW Medical Center
Chippenham Campus
804-228-6527

msjones · February 2013

I agree. I am the only CDI specialist @ our hospital and our program was started 8 yrs ago. I work in the same office with the coders and we talk daily. Our HIMS manager is located in the same office and if there are issues the coder and I can't resolve we go to her immediately. It has worked great!

Michelle Jones, RN, BSN
Clinical Documentation Specialist
Vidant Roanoke Chowan Hospital
252-209-3012
msjones@vidanthealth.com

sharon.cole · February 2013

I have to agree with this post (not sure who it's from). When we first began our program it was all about capturing CCs (and then MCCs when we moved to MS-DRGs). It wasn't until we were able to hire a coding professional that we even considered the "true" PDX and other important documentation needs such as clarity and completeness. Then once I learned about ACDIS and attended my first conference, my eyes were certainly opened. I began searching for supporting documentation to support what I was querying for, began arguing with our consultants that just because the albumin was 3, I was not going to place a malnutrition query, same with SIRS criteria, etc, etc, etc. Our first CDI Leadership meeting with admin I was asked - if it's just to clarify documentation and not money, why are you wasting your time placing a query. It took a long time but eventually even admin understood better that we needed to be able to defend our records, not just bill for the highest DRG.
It's been funny to watch the consulting firm, change and begin teaching what I was telling them - you need more than an albumin for malnutrition, you need more than just 2 SIRS criteria for sepsis, etc. Basically saying the same things I had been arguing with them about for the past 5 years.

It has certainly been an enlightening journey!

Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org

evanspx@sutterhealth.org · February 2013

Hi, Donna

I took no offense at all from your comments and thank you, and everyone, for offering their perspectives on the issue. It is complicated, and probably a truly iformed conversation can't be had via a chat on-line.

I think all agree concurrent CDI chart reviews are Best Practice. However, the reality, I think, is that retrosepctive queries are also neccessary for a number of legitmate reasons. I do not believe there is an inherent compliance risk in a retrospecitve reivew that is performed compliantly. Work flows and CDI staffing probably means that facilities should have the option of retrospective reviews.

Paul Evans,RHIA, CCDS

evanspx@sutterhealth.org · February 2013

I don't agree - the realities of working day-to-day in a vibrant and very busy medical facility mean to me that I must always have retrospective reviews performed compliantly as an option. There is simply no way any CDI program can address 'each and every' documentation issue that may arise concurrently.

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

parrispa@musc.edu · February 2013

I agree Paul, and the fact of patients being discharge so quickly these days lends to the issue.
pam

Pamela Parris,RN
Clinical Documentation Integrity
MUSC
Charleston, South Carolina 29425
Pager: 12295
(843) 792-3442
MAIN HOSPITAL

evanspx@sutterhealth.org · February 2013

Dorie - nicely stated. My overriding point on the issue is that an RHIT/RHIA 'is' capable of performing CDI duties concurrently - indeed, we have unique educations ideally suited for the task. This is not to say that others should be precluded from the profession - the skills, education, talent and training of each INDIVIDUAL must be considered. Further, attainment of the CCDS credential is 'supposed' to convey this competency.

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

tkreiling · February 2013

We have to do retro queries for path results or other lab results that may come back after the patient is discharged, I do not look at it as a reflection of a deficiency of our CDI program but more of timing of when results may come back. Therefore, it is another example of when retro queries may be needed.

Tara, RN,CCDS

evanspx@sutterhealth.org · February 2013

It is unfortunate they resist CDI given I am sure you make their jobs easier by clarifying key terms in the record.

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

sharon.cole · February 2013

I think the main point here is lack of understanding. Physicians don't understand that what they write gets turned from verbiage into numbers. Furthermore and more importantly, they don't understand WHY their verbiage doesn't translate across the board into those numbers (they don't have time to read coding clinics).

I had a discussion with one of our intensivists the other day, who argued that he didn't need to write out the word systolic when he addressed the Echo in his note and referenced that the EF was 20%. He told me that somebody should state that an EF of 30 or 40% should automatically be considered systolic dysfx, then he walked away in a huff. He came back a few minutes later and began griping some more so I asked him WHICH doctor/specialty should determine if it was 30% or 40%. He stomped away and then came back again and said, just make it 30. I asked him what I should do if he consulted cardiology on one of his patients who had an EF of 40 and the cardiologist called it systolic. He stomped away again and came back about 20 minutes later, started to say something and walked off muttering to himself. He finally came back and added systolic. Told me the whole coding thing was stupid and left. I made him a valentine - see attached:). He laughed and told me, he'd try to remember to be specific.

Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org

lsipos@monument.health · February 2013

: Love IT!!!!

Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"

"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

paxneros · February 2013

PRICELESS!!!

This mist become part of the Forms & Tools Library!!!

NBrunson, RHIA,CDIP,CCS,CCDS

sharon.cole · February 2013

You are welcome to it. One of my colleagues jokingly suggested it and I created it.

Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org

No need for CDI?

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