E-News Exclusive

Bring Together CDI and Coding Teams to Drive Optimal Documentation Results
By Dianne L. Haas, PhD, RN, and Alice O. Zentner, RHIA

An old African proverb states, “If you want to go fast, go alone. If you want to go far, go together.” This concept takes hold in healthcare as HIM professionals struggle to improve clinical documentation—the foundation for optimal coding, reimbursement, quality reporting, and continuing patient care. Working in silos for decades, clinical documentation improvement (CDI) specialists and clinical coders now are joining forces for better documentation outcomes.

This article explains how to bolster CDI performance through CDI specialist and coder collaboration.

Traditional CDI Falls Short
Traditional CDI programs often fall short of intended goals and desired outcomes. A recent TrustHCS survey revealed that hospitals rank CDI program effectiveness at only 3.25 out of 5. Furthermore, 34% of hospitals don’t even have a CDI program in place. Stated reasons for poor performance include failure to conduct program audits, insufficient staffing, and lack of continuing education.

However, with ICD-10 rapidly approaching and the negative impacts of poor documentation becoming better understood, executive focus is turning to CDI. This is particularly true for multilocation healthcare organizations and those sharing data within a health information exchange or an accountable care organization. Commonly documented concerns include the following:

• Coders are forced to use nonspecific codes, resulting in lower-paying diagnosis-related groups (DRGs) and faulty case mix index.
• Quality scores and Healthgrades reporting are skewed because the data fueling them are based on incorrect documentation and do not accurately reflect quality of care, placing organizations in a one-down position in local and regional care markets.
• Ongoing patient care is impacted when the next physician in line is unclear or misinformed.
• Additional costs may be incurred as physicians are forced to repeat tests and exams.

Because of these concerns and many more, organizations are exploring new models for CDI initiatives, including bridging the gap between CDI specialists and coders.

Integrating CDI efforts across the entire healthcare organization and departmental silos is becoming an important component of continual documentation improvement. CDI professionals, medical staff, revenue integrity experts, and clinical coders must be seated at the same table to positively impact reimbursement and quality reporting. A critical role for HIM professionals within this enterprise initiative is to bring closer together CDI specialists and clinical coders.

Get It Together
Organizations that coordinate documentation by bringing together CDI professionals and clinical coders report a reduction in recovery audit contractor (RAC) take-backs and third-party payer audits. Stronger documentation teams have resulted in better financial outcomes for all.

Recent attempts at CDI specialist/coder collaboration have revealed some important benefits. Simply getting CDI specialists and coders to meet together starts the ball rolling and assuages executive concerns related to documentation and coding under ICD-10. We have observed the following conversations immediately on combining the two teams:

• identifying problems with current methods and workflow;
• brainstorming solutions for day-to-day issues;
• recognizing deeper levels of connectedness; and
• valuing unique strengths and what each brings to the CDI program.

Once brought together, the need for ICD-10 training presents an optimal opportunity to build CDI teamwork.

Combined ICD-10 Training Builds Teamwork
Combined training leverages clinical coders’ knowledge of DRGs and revenue alongside CDI specialists’ understanding of physician documentation patterns and practices. Furthermore, as providers ramp up for ICD-10, dual training helps both teams understand how much more information will be required. They then may work together to educate clinicians.

Coders who already have undergone basic ICD-10 training recognize the gap in documentation requirements between ICD-9 and ICD-10. They can articulate the new “must-haves” directly to the CDI specialist team. Likewise, CDI professionals can think ahead to future physician discussions on the nursing unit. Dual training helps them gradually revise queries, including information and specificity required with ICD-10. Through this process, physicians become familiar with additional documentation requirements well in advance of the October 1, 2014, deadline.

Several CDI services companies already have combined their educational offerings and many more are doing so. ICD-10 training and coding services companies also recognize the value of dual-training strategy and are incorporating this methodology into ICD-10 curriculums.

Training should be offered in both online and on-site modalities. The online materials reinforce biomedical basics such as anatomy and physiology, medical terminology, pathology, and pharmacology. Application and synthesis of this knowledge is provided in on-site didactic educational sessions and hands-on ICD-10 coding experience in all the major diagnostic categories and in ICD-10-CM/PCS for both CDI and coding teams. Once training on ICD-10 and collaboration is under way, new workflows can be developed to maintain and strengthen the new relationship.

Reinventing CDI Specialist-Coder Workflow
Many organizations already bring CDI and coding together monthly. However, daily communications and a fully integrated workflow drive faster results. According to Adelaide La Rosa, RN, BSN, CCDS, corporate director of HIM/CDI/charge description master at Catholic Healthcare Services in Melville, New York, monthly meetings between CDI and coding aren’t enough to form a strong working relationship. In presenting to a recent Association for Clinical Documentation Improvement Specialist meeting, daily communications are a necessity before final bill drop to achieve the following four common goals:

• make every case RAC-proof;
• validate each DRG;
• support all complications or comorbidities (CCs); and
• document the quality of care the organization is providing.

There are three workflow steps to reach these objectives and accommodate optimal CDI:

• Throughout the morning, coders work in HIM to code cases as concurrently as possible. While coders assign codes from the prior days’ discharges, CDI specialists meet and discuss cases with physicians in the nursing units.
• In the afternoon, coders and CDI specialists meet and review the assigned codes. They can be teamed by unit, diagnosis, physician, or any other practical working criteria. For each case reviewed, the CDI specialist notes whether any further diagnosis, CCs, or procedures should be documented, queried, and coded. Armed with this knowledge, the CDI specialist discusses the case with the appropriate physician the next morning, gets answers to any queries, and relays information back to the coder.
• In the afternoon of the second day, the CDI specialist gives the final blessing to assigned codes, and a final bill can be dropped.

Skills needed for the last step include knowledge of both CDI and coding. Daily interactions ensure that a deeper level of understanding is developed and maintained.

A Stronger Bond
At the end of the day, coders and CDI specialists are both focused on getting a good, clean bill out the door and into the hands of payers. By working together, both teams can achieve this goal. Mutual support and an easy, open exchange of expertise form a deeper bond and break down departmental silos.

— Dianne L. Haas, PhD, RN, is executive director of consulting at TrustHCS.

— Alice O. Zentner, RHIA, is director of ICD-10 auditing and education at TrustHCS.