Coding and CDI: It Takes Two

In understanding each other’s role in healthcare reimbursement, coders and CDI specialists make a dynamic duo.

In healthcare, we can no longer work in silos, separate from each other, doing our own thing, unaware of what other staffers are doing. We must work collaboratively, as a team that extends past our own departments. Value-based healthcare requires all healthcare business professionals — patient registration, precertification, clinical documentation improvement (CDI), coding, billing, revenue integrity, etc. — to work together, striving to do our individual best, while understanding how each area affects another.
Coding and CDI, for example, are both vitally important to our health systems. CDI has been solely focused on the inpatient facility setting, but it’s on its way to the outpatient facility. As in the inpatient setting, CDI specialists in the outpatient setting can educate providers on the quality of their documentation. A CDI specialist also needs to look at documentation as it pertains to risk adjustment and hierarchical condition categories (HCCs).

Understand the CDI Specialist’s Role

CDI specialists are typically registered nurses. Some have a Certified Clinical Documentation Specialist (CCDS) credential, as well. These specialists focus on the clinical picture. They help to educate physicians on improving their documentation for patient care and safety.
In the inpatient setting, CDI specialists typically focus on concurrent (while the patient is still in the hospital) reviews of the patient’s chart. They review the documentation to be sure it reflects an accurate clinical picture of the severity of illness for the patient, for quality measures, for specificity, and to query the physicians for clarification when necessary. Ideally, by the time the chart gets to the coder, it’s as complete and specific as possible. Being on the floor reviewing data also helps the CDI specialist to build a rapport with the physicians and floor nurses. After the patient is discharged, the review becomes retrospective (after the fact).
CDI specialists also review claim denials for appeal appropriateness and collaborate with the coder for clarification on the codes to aide in the appeal, as well as for educational purposes.
The CDI specialist can’t review every chart because there just isn’t enough staff or hours in the day. To narrow the scope, chart reviews can be done by top volume diagnosis-related groups (DRGs), surgical DRGs, DRGs for quality measures, specialty, specific principal diagnosis selection, etc.

Work Together to Improve Outcomes

In the inpatient setting, both the CDI specialist and coder assign codes in their respective part of the encoder, resulting in a DRG based on the principle diagnosis, principle procedure, and diagnoses that are complications and comorbidities (CCs) or major complications and comorbidities (MCCs). A CDI specialist’s DRG is considered a working DRG (meaning: the patient is still “in house”). The coder’s DRG is the final DRG (meaning: after the patient has been discharged).
The CDI specialist can often help the coder better understand the clinical prospective of the chart and make sure the coding is reflective of the clinical picture of the stay. The coder can help the CDI specialist understand the guidelines and determinations that affect coding. For instance, a combined code can have a different effect on the DRG than coding each diagnosis individually.

Open the Lines of Communication

If the CDI specialist and coder do not end up with the same DRG, it’s considered a DRG mismatch. This situation requires the CDI specialist and coder to have open and effective communication about the differences in the pre-diagnosis, procedure, CC/MCC, etc. Sometimes, the difference in DRGs will lead to further discussion of coding guidelines or the clinical perspective. Sometimes, it will lead to a provider query for clarification. Who queries the provider depends on the patient’s status. The coder is the one to query the physician if the patient has already been discharged. It’s important to notify the CDI specialist of the answered query, so they can go into the working DRG and update their information.

Defining DRGs and HCCs

DRGs are the payment methodology for inpatient facility claims. They relate the type of patients treated (the case mix) with the costs incurred by the hospital. Think in terms of a “lump sum” payment. Some of the secondary diagnoses are considered either complications and comorbidities or major complications and comorbidities. They play an important role in the reimbursement process in that they can increase the DRG payment because of the need for additional resources and can explain why the length of stay was longer than typical for a DRG. Risk of mortality and severity of illness are secondary diagnoses that can have an impact on the DRG and explain why more resources were needed and/or a longer length of stay.
The Centers for Medicare & Medicaid Services – Hierarchical Condition Categories (CMS-HCC) model generates a risk score for each patient that summarizes their expected costs of care relative to other patients. Similar to DRGs, HCCs account for demographics and clinical conditions (diagnoses) in measuring risk. Expected patient costs are calculated, adjusting for outliers based on the patient’s risk score and whether the patient has end-stage renal disease. The risk-adjusted measure compares the provider’s actual per capita costs with its expected per capita costs, allowing CMS to adjust payments accordingly.

Gain Knowledge, Share Knowledge

In the outpatient setting, the CDI specialist also needs to learn CPT® and evaluation and management (E/M) services guidelines. Outpatient coders are very adept at interpreting these guidelines and are instrumental in educating CDI specialists.
Both coders and CDI specialists can benefit from obtaining AAPC’s Certified Documentation Expert Outpatient (CDEO®) credential to validate their expertise in reviewing outpatient documentation for accuracy and the ability to support coding, quality measures, and clinical guidelines.

Related Reading on the Knowledge Center

For more information about HCCs, read “Be an HCC Coding Hero in the ED,” featured in the May 2018 issue of Healthcare Business Monthly.
For more information about querying physicians, read “Query Physicians to Improve Documentation,” featured in the March 2017 issue of Healthcare Business Monthly.

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Kimberly Farley

Kimberly Farley, CIC, COC, CPC, CHONC, is an inpatient coder in Lowell, Ohio. She has been in healthcare for 23 years, initially in a surgical practice before transferring to facility coding. Farley served as education officer for the Parkersburg, W. Va., local chapter in 2019 and 2020 and member development officer in 2011 and 2012. She has also presented at chapter meetings.

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