In my discussions with clinical documentation improvement (CDI) teams and their hospitals, there is a rather disturbing trend that has come up too often to ignore. The polite way to say it is, “There is an opportunity to improve collaboration between the professional coding staff and the clinical documentation specialists (CDS).” Okay, let’s be honest: in some cases, there are outright territorial disputes that border on open warfare. Here are some of the issues that I have encountered:
– The assertion that coders do not ever want to use more than one computer program. The CDI team might have one application, while the coders have another. While this may be understandable, this philosophy limits the opportunity to take advantage of true online concurrent collaboration with the CDS staff, something that should be sought and welcomed in the new world of ICD-10.
– Failure to attend the same training sessions. This is the most logical place for team-building to start. It is always difficult to get everyone in the same room together, but some hospitals find it particularly challenging to plan CDI training for coders who are scheduled to be doing production coding. Even when the coders are expected to use the CDI software program, they often schedule a separate session from the CDI team.
– Historical lack of a sense of being on the same team. This may be aggravated by a sense of indignation on the part of coders, feeling that the CDS (lacking all of the professional training of a coder) is being asked to do part of a coder’s job. When the CDI program reports up through a department other than coding, this sense of separation is further widened.
– Mismatches of the final DRG between that derived by the CDS and that derived by the coder. These can lead to further divisiveness, despite the fact that they are to be expected. It is not reasonable to think that they will always match, but when a mismatch happens, it is an opportunity to learn, not to fight.
– Who gets credit for the query? I saved the most befuddling issue for last. It seems that, in some instances, two opposing teams (coders and CDSs) are vying for credit for the increased reimbursement that will result from the answering of a query.
So, how can this situation be improved? Here are a few suggestions:
– There should be strong and consistent support “from the top” for fostering collaboration. When all stakeholders agree on the goal, then the steps to get there (such as adding modern CDI collaboration tools) make sense. Begin the focus on “what,” and the “how” will then follow more naturally.
– Make it a priority to have portions of initial training for programs that are starting or in transition to be held jointly between coders and the CDI staff.
– Established CDI programs should schedule periodic joint sessions to identify and address key problem areas. Session titles might take the form of “Documentation and Coding of ___________,” with specific topics, including malnutrition, sepsis, hypertensive emergencies, etc.
– Another good topic for periodic meetings is to discuss DRG mismatches that have been identified. Remember, mismatches are to be expected, but can still offer an opportunity to learn.
– Set joint goals for documentation and coding improvement, rather than trying to have one side or another getting credit.
The end-goal is to create a complete and accurate record of the patient encounter, whether for coding and billing purposes or for documentation and quality purposes. Start building bridges between your CDSs and your coders, and you’ll see improvements in your results.
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