Lynn Salois, RHIT, CCS, CDIP, Director of Coding

Situation:

Some to do list items appear more challenging than others, or so we think. For example, creating an environment of teamwork and collaboration amongst the Coding and CDS group may seem like a monumental task, but in reality, it can be very simple.

Begin with fostering two basic core values:

Communication and Respect

To ensure everyone is on the same page, begin with communicating the team goals and expectations to both groups during a roundtable discussion. Next, is a cultural change for many healthcare organizations – tear down the silos – allow the two groups to work together as one team. Schedule regular team meetings to discuss workflow issues, DRG mismatch cases, problematic queries, coding and documentation issues. Allow the groups to talk to each other whenever the need arises to brainstorm a coding or documentation issue. Create a coder/CDS pairing whereby each coder is paired with a CDS to review individual records to discuss and resolve issues.

Respect

Very often the rules and regulations governing the coding group appear a bit confusing or over the top to most clinicians. (Sepsis must be documented in the discharge summary). Be respectful of the expertise of those within the group and respect and abide by the rules and regulations governing each group.

Take a moment to think about the braintrust for clinical documentation integrity being created by tearing down the silos and communicating. It is that simple!

What are your thoughts?