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Wiki Cdi

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mommacode

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Of course the majority of people on this site are coding outpatient, but I am curious how many inpatient coders will respond. The CDI program is designed to help the hospital improve its documentation and coding. It is my understanding that the CDI is to analyze the record prior to the coder review and if there is anything documented that is not supported by the labs, treatment, testing, etc the CDI is then to verify this with the physician. The CDI is not to just decide based on the review of the record that a diagnosis that has been documented is not coded. What is the correct method? For example, if the documentation by the physician states acute renal failure but the labs only show a small change in the creatinine and the CDI feels this is not the criteria for acute renal failure, can the cdi and coder leave off the dx of acute renal failure without verifying this with this physician?
 
Query the provider and make sure what is written in documentation is correct, due to the labs being conflict. You cannot not diagnosis or make assumptions that the labs are correct, or the provider is incorrect. Clearer documentation is needed from the provider.
 
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