Strong communication between clinical documentation specialists (CDS) and clinical coders is vital to the success of any clinical documentation improvement program. But additional benefits may be gained through ongoing exchange between these two teams. Here’s a real-world example.
In reviewing the medical record, the coder notes disconnect between the physician documentation and the CDS documentation.
The initial physician documentation indicates pneumonia. His later documentation indicates acute bronchitis. However, the CDS worksheet only indicates acute bronchitis.
Was the pneumonia ruled out?
Did the CDS obtain pertinent information about the patient’s diagnosis while attending physician rounds? Is there an outstanding query to clarify whether the pneumonia was ruled out?
Here are my thoughts…
- While code assignment may not be based on CDS documentation, many CDS’s attend physician rounds. They obtain pertinent information about the patient’s diagnoses and treatment plans. CDS insights are extremely valuable to clinical coders. Use CDS documentation to create a query opportunity, clarifying and/or specifying physician documentation.
- Reach out to CDS to determine if information was obtained indicating the pneumonia was ruled out and if a query response is pending.
- Communication between the CDS and Coder ensures completeness of clinical documentation and coding accuracy.
- Use CDS worksheets as a valuable tool during the coding process.
What are your thoughts?