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September 12, 2011

Experts Say Coders Can Excel As CDI Specialists
Robert S. Gold, MD, and Cassi L. Birnbaum, MS, RHIA, CPHQ

For The Record
Vol. 23 No. 16 P. 6

A segment of a blog that appeared August 12, 2011, in Advance’s Health Care POV has raised some interesting issues. We congratulate the author for a well-composed description of her targets, but wish to object to a few of the concepts described.

Certainly, it is apparent that the author came into the clinical documentation improvement (CDI) field just prior to the adoption of Medicare severity diagnosis related groups (MS-DRGs) and underwent that transition with many of us “old-timers.” The insights from that evolution gave her hands-on experience in dealing with her subject, the documentation and coding adjustment. And although I’m sure that her professional nursing career was a glorious one, we believe she developed some incomplete perspectives of what a CDI specialist is.

The clinical documentation improvement program at West Penn Allegheny Health System was provided by a “major consulting firm” that helped the facility set up the position description for its CDI specialists—it’s their right. Some of the criteria for those positions are described in the article as “a minimum of five years of nursing experience and a bachelor’s degree.” This model created a specific division between nurse/CDI specialist and coding professionals, which has been the standard for the 20 years prior to the start of its program—a model that evolved from the case management department additional hat of CDI—“let’s give her more responsibilities since she’s already in the chart.” Most facilities, including this one, have developed the dedicated CDI specialist and have separated that function from case management (thank goodness).

We get the impression that the author’s consultant training focused on a DRG optimization and along the lines of “because nurses are the only ones who can understand what the physician is saying, we will fight the doctors and the coders to get what we want.” She states the following:

“Coding professionals know all the coding rules but they do not see the chart until after discharge; also, coding professionals are highly trained but do not have clinical expertise. CDI specialists are clinicians (usually nurses) who ‘speak’ the same language as physicians and understand their documentation nuances. Combining our medical knowledge with our CDI training allowed us to review charts and find opportunities to improve documentation while the patient was still in the hospital. Coding professionals often find clarification issues, but not until after discharge, and physicians may not want to update their documentation after ‘Elvis has left the building.’ CDI specialists can catch the physician in person, by phone, or by e-mail, query about ambiguous or incorrect documentation, and improve the quality and clarity of the documentation while ‘Elvis’ is still in the bed.’”

Extremely picturesque and very innovative—we like the way the author described her perspective of the situation—but we significantly disagree with her viewpoint. A CDI specialist is a person who knows ICD codes and the documentation needs that will permit assignment of appropriate ICD codes, who is trained in and understands clinical aspects of disease process, anatomy and pathogenesis of illnesses including treatments, procedures, and pharmacologic aspects and who can communicate between direct providers of healthcare and coding professionals. That said, the CDI specialist can be a clinician who knows coding or a coder who knows clinical. And anyone who believes that a coding professional cannot become clinically astute has not become enlightened and has been “led to the dark side of the force.”

A coder who does not take the time to learn clinical has no business in CDI—that’s for sure. Denying that coders can become as astute as an RN is equally inappropriate. We have trained many coding professionals over the years. Some have gotten it; some haven’t. Some are successful; some aren’t. All the ones who have gotten it, who are successful, have the strong support of the medical staff and midlevel providers at their facilities as a colleague and not “just a coder.” These professionals not only can identify the appropriate cardiac dysfunction that led to acute or chronic left ventricular failure, they intuitively and by training know the breakdown of all of the subheadings of obstetrical pulmonary embolisms while we’ll wager the average RN can come up with only one or two.

To state that coders only live in the retrospective world of the dungeons of the hospital is faulty. A coding professional, properly trained as a CDI specialist, can do the job just as well as a nurse trained in coding.

— Robert S. Gold, MD, is CEO of DCBA, Inc, and a member of the For the Record editorial advisory board.

— Cassi L. Birnbaum, MS, RHIA, CPHQ, is an AHIMA board member and director of health information and privacy officer at Rady Children’s Hospital of San Diego.