Unfortunately, the silos between coders and CDI professionals still exist in many hospitals. In some organizations, the walls may be slowly coming down, but in others, the silos stand tall. The irony is these two roles actually have more in common than they might realize. With communication and collaboration, coders and CDI specialists actually have the power to make a significant difference in patient care. Think about the common goal: To ensure patient safety and quality of care. This is the goal regardless of whether it’s achieved through the documentation in the record or those codes that reflect the care provided.
A healthy relationship between coders and CDI specialists begins with reciprocity. How can coders help CDI specialists make the transition to ICD-10? How can CDI specialists help coders make the transition to ICD-10? Below are a few of my thoughts.
For Medical Coders
- Educate CDI professionals about the most-frequently reported diagnoses for which more specified documentation is required in ICD-10. For example, when documenting acute respiratory failure, CDI should ask physicians to specify whether it’s “with hypoxia” or “with hypercapnia.” For procedures, CDI must ensure that documentation reflects the approach, body part, and laterality. These conversations are probably already taking place, but it’s a good idea to revisit them and review the most important information.
- Serve as a “second set of eyes” during coding to provide back-up support for CDI. CDI specialists can’t possibly review every record. That’s why they need coders’ help. Coders should ask these questions: Did CDI specialists miss something? Did a physician forget to respond to a query? Perhaps the CDI specialist didn’t review the record right before discharge, and new information was presented. Coders must always be on the lookout for documentation improvement opportunities while coding.
For CDI specialists
- Ask coders what they need. What information is typically missing, and how can CDI specialists be more proactive in obtaining that information? Keep in mind that coders are coming to you because they need your help and expertise—not because they want to overwhelm you with work.
- Inquire about dual coding results. What have coders found, and what do they need? Do templates exist to help capture some of this information? Can you ask for it automatically?
Patience Is Critical
Patience is a virtue, and this could be truer than in ICD-10. CDI specialists need to be patient with coders who will frequently ask them to query physicians for additional information. CDI must remember that this is part of what coders are required to do per the new code set and guidelines. Likewise, coders need to be patient with CDI specialists, many of whom might not have had proper or thorough ICD-10 training.
As we enter the home stretch, let’s try to make the transition as smooth as possible. Ask yourself this question: How can I be a team player and open the lines of communication with others?
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