The multitude of changes in the healthcare industry are forcing hospitals to re-design and re-energize their Clinical Documentation Improvement Programs. To assist in this endeavor, HIM Directors and coding managers should examine the existing relationship between the two driving forces behind the success of the CDIP. Regardless of whether it appears the HIM coders and CDS are working together collaboratively toward their common goal of data integrity of coded data and clinical documentation, investing time in validating a true collaboration will be worthwhile. Things may be bright and sunny on the surface but digging deeper into the relationship may yield their daily struggles of finding a common ground with their differences of interpretation, opinions and understanding of coding guidelines, query opportunities and documentation requirements are ongoing.
Here are my thoughts…
The first step to accessing the HIM Coder and CDS relationship begins with data analysis. Below are the top fifteen questions to initiate the process.
- What is the current level of communication between these two groups? Daily, weekly, monthly or as needed? What is the mode of communication? Face to face, telephone, or email?
- Do the two groups value and respect each other’s subject matter expertise?
- Are scopes of work, level of responsibilities, work flow processes and final decision making authority for the two groups clearly defined?
- Are CDS review sheets, queries and final DRGs accessible to coders (both internal and contract coders) at the time of final coding?
- Are unanswered CDS initiated queries referred back to the CDS for follow through?
- Who is responsible for retrospective queries?
- Are CDS and Coders querying for SOI/ROM coding and documentation opportunities?
- What is the process for handling data integrity issues?
- How frequently do discrepancies between the CDS DRG and Coder DRG occur and why?
- What is the process for handling unresolved DRG discrepancies? Who facilitates this process?
- How are CDS identified “missed coding opportunities” handled?
- How are coder identified documentation and query issues handled?
- How frequently does a “agree to disagree occur”? How are they resolved? Are these cases escalated to management for resolution?
- What is the role of the CDIP physician advisor?
- What is the reporting structure for HIM coders and CDS?
Next Month: Part 2 – Analyzing the Data and Implementing Change for Improved Collaboration
What are your thoughts?