This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
If a couple were to decide they wanted to build a house, they would need to communicate regularly to complete the home and make sure it fit the needs of both of them. If one of them were to say, “We need three bedrooms,” and the other one instead said, “No, we must have four bedrooms,” they could become very frustrated with each other if there were no further communication. Consider instead if they were to include more detail to support their ideas for the number of bedrooms, such as, “I think we need three bedrooms to save on the square footage and have more room outside for a garage,” or, “I would like to have a fourth room for an office, maybe we can add a loft so we also have room for a garage.” In this scenario of more detailed communication, each person expressed the reason for their request, which helped them to develop a solution for both of their needs.
As with any partnership in life, such as the couple building the house, the relationship between the clinical documentation improvement (CDI) specialist and the coding professional is crucial to the success of a CDI program. Each specialty brings essential knowledge from both clinical and coding backgrounds. Why then do we see frustration build so frequently between these two areas?
It’s a difficult question to answer. Some frequently heard questions regarding this relationship are listed below, along with possible solutions.
- Who gets credit for the query impact? In some organizations, query impact is only measured for the CDI specialist teams and not the Coding Professionals. Many CDI teams cannot review every record, thus relying on the coding professionals to identify documentation gaps after discharge. Coding professionals have been sending queries for many years and when their work is not measured, it can add to frustration.
- Who has the final say when DRGs don’t match? In many CDI programs, the CDI specialist will assign a working DRG and the coding professional will then assign a final DRG. This situation can result in some intense dialogue when both teams feel strongly about the DRG they chose. Teams should have open dialogue and hopefully find solutions when hearing the facts. When a solution cannot be determined, there should be an escalation process in place for the teams to rely on for final determination.
- Which is more important: the clinical or coding perspective of the case? Both the clinical and coding perspective of the care are very important and should be considered in each case. Any diagnosis coded should be supported clinically and the coding guidelines must be followed. This is another situation that should have an escalation process in place.
It is important to have strong communication and open dialogue when building a CDI team. It is important for teams to feel supported and have a process in place when tough questions arise. When teams learn that different perspectives are beneficial not only within the team, but also for helping to strengthen and educate each professional, mutual respect then develops.
Now it’s your turn! Let’s continue to learn from each other. Have you seen conflict arise between the CDI specialist and coding professional at your facility? If so, did you find a root cause and what solutions have you implemented? Does your CDI program have an escalation policy in place to resolve conflicts?