Reviews of medical coding and CDI practices can often reveal gaps in the latest trends for specific types of records, shedding light on areas where coding and CDI may not be in alignment. By identifying these discrepancies, hospitals and healthcare organizations can take steps to improve overall record quality and ensure that coding and CDI efforts are in sync.
Here are some best practices that can help bridge the gap between Medical Coding and CDI departments:
- Sharing audit review results and education with each other.
- Staffing a medical coder(s) to work with CDI concurrently.
- Pairing a medical coder with a CDI specialist for individual support.
Sharing trends found in reviews and education with each department can assist in identifying and rectifying repeat clinical scenarios or coding scenarios that were previously challenging. This can also provide more consistency in reporting from both departments.
In reality, due to staffing and time limitations, not all visits can be reviewed for CDI concurrently. Without bridging the two teams, this can create a gap in documentation if clinical queries aren’t provided to clarify or specify diagnoses which can result in inconsistent reporting impacting quality and revenue.
To have a better understanding of clinical indicators and application of the Official Coding Guidelines and AHA Coding Clinics each department could:
- Improve the number of mismatches
- Improve quality/clinical outcomes
Increased collaboration amongst teams through education and training can facilitate coding support and ensure adherence to established protocols for similar record types (e.g., shock, respiratory failure, myocardial infarction). It does not mean that the medical coder needs to identify all CDI opportunities but if they see a clinical scenario that seems off or questionable, they can reroute the record to the CDI specialist marking it as a possible opportunity.
MRA offers customized medical coding and auditing solutions to help healthcare organizations accomplish their goals. Connect with our team of specialists to discuss your hospital or healthcare organization’s ongoing needs.