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CDI: Just Tell Me What to Say

Coders, CDI Specialists and Physicians: Creating A Symbiotic Circle

Published July 2, 2012 11:36 AM by Alice Zentner

At the recent AHIMA ICD-10 Summit, one message was completely clear: The most important element of ICD-10 preparation process is clinical documentation assessment and improvement. And the best news from the summit? Any efforts you expend now toward better documentation for ICD-10  also will deliver improvements in ICD-9.

Here are five reasons to start now:

- improved patient safety and quality care

- more accurate public reporting

- reduced denials and audits

- fewer physician queries and coding delays

- improved case mix index.

Time and time again my firm is being called in to assess clinical documentation in preparation for ICD-10. Documentation is the first place to look for potential pitfalls and gotchas. Coding is the second. Clinical documentation and coding are like the two bookends in improving all five issues mentioned above.

But many organizations are struggling to find an effective starting point - one that will demonstrate quantifiable improvements and cost-justify ongoing efforts. In our experience, here are the five sure bets to deliver the proof your program needs:

Step One: Identify your top MDCs.

Step Two: Conduct CDI and coding audits for the top DRGs within each of these MDCs by coding cases in ICD-10 and comparing results. Also called a CDI assessment, you'll quickly see which DRGs will cause future problems should documentation and coding remain "as is."

Step Three: Bring CDI specialists and coders together for MDC-based training. Spend one day on each MDC reviewing basic anatomy and physiology, common diseases, treatments and medications.

Step Four: Team up CDI specialists with coders for specific diagnosis and procedures to strengthen the relationship and mutual understanding.

Step Five: Rotate CDI specialist and coder pairings until all top MDCs and DRGs within those MDCs are covered.

Step Six: Measure your improvements.

By taking a MDC-based approach to CDI and coder training, quick, quantifiable improvements are bound to occur. These two professional teams are different in background, mindset and "thought-flow." The sooner you bring them together at the same desk and make them a team, the better.


Very nice assesment.  From what I have learned so far in my classes the above statement could not be more true.

Rebecca Machal, Billing and Coding - Student, MedTech July 22, 2012 11:11 AM
Lexington KY

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