# Clinical documentation specialist



## mommacode (Aug 15, 2014)

I am wondering if anyone out there has any good information for me to clarify what the role of the clinical documentation improvement specialist really is. I work for a facility that has a CDI program and let me try and briefly explain what they do. They are all nurses first off. What they do is get the records and put codes on it just like the coder would. Most of the time they are all incorrect. Then it goes to the coder and they code it correctly but they are required to get the cdi's approval on their code selection even though the cdi had it wrong to begin with. The CDI never go to the floor and talk with the physicians about anything nor do they query for any documentation issues. It is always the coders catching everything. Another thing that we are told to do is we have guidelines that the coders are required to know and instead of the CDI using these clinical guidelines to consult with the provider for proper documentation we are told to just "leave off" certain things that are documented in the record. For example, if chronic respiratory failure Is documented but the patient is on less than 15 hours of oxygen therapy we are told we cannot code it. I feel that the coder should code what is documented and if those clinical guidelines are to be used they should only be used by the cdi to get clarification from the provider before it gets to the coder. I really think that my facility has somehow misconstrued the job of the cdi and I am hoping to find some info from others on how their program is done and hopefully find some info to prove this point to my employers. The cdi program is not intended for the nurses to sit in cubicles in the medical record dept and pretend code while the coder is the one really doing all the work and looking and clinical info.


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## jorzano55@gmail.com (Aug 15, 2014)

WOW....have worked in 2 very large facilities in last 3 years with CDI's never heard of such a situation.  Have a lot to contribute to your post.  Please feel free to contact me direct at jorzano55@gmail.com.  Jo Anne


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## ErikAZ (Aug 16, 2014)

There are two scenarios for CDI that I've found.  The first scenario is "Ideally" the CDI should be concurrently analyzing the patient record while in house paying attention to clinical information (labs, radiology, etc) and querying the provider for possible diagnosis documentation opportunities.  For example if I see a low sodium lab level I think hyponatremia which is a CC condition that will affect the DRG.  I'll then write a query inquiring "is there a clinical diagnosis that can be made relating to these lab values".  The CDI also should be on the floor speaking with physicians about documentation and what is required.

The second scenario is "Reality" for many.  Often CDI seems more like concurrent coding in that they'll focus on chart documentation and queries that seek clarification (for example type and acuity if CHF is documented).  This is more a coding role and typical of coding queries.  

Personally (as a coder) I believe it's easier for a coder to learn the clinical clues than it is for a nurse to learn the coding requirements.  I have coders on my team that are very clinically minded who recognize "this plus this equals that".  

One wild card in all this is that many payers now doing "DRG Coding Reviews" are actually doing clinical reviews.  As I process insurer letters I find more and more are now stating that "while it's documented they didn't clinically have it".  It's a change from the old "this was never documented".  This has forced coders to become more clinical.  We have situations where a doctor documents something and we say "they didn't have this".  I go so far now as taking a query to the doctor and talking to them to confirm they had it and asking them to document clinically WHY they have it.  Often it can't be justified clinically and they will admit it and we don't code it.  Given the new clinical focus of "coding audits" I don't believe just coding what is documented is written in stone like it used to be.  We're not really "just coders" now.

It's a real balancing act.  

ErikAZ


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## soccermomof6@hotmail.com (Aug 17, 2014)

I agree Erik, it is a real balancing act. I worked in an Acute care facility & the CDI team was definately on the floor reviewing records & querying Dr.s so that when it got to the coder any questions were answered & we could code the chart. I had a Dr. document 'acute repiratory failure' once & the CDI came back & said there wasn't enough evidence of this & recommended I remove the code. I believe the CDI role is more to protect the Hospital from any potential audits. They keep abreast of the CC/MCC's that are being questioned by RAC's & make sure if the chart was audited the documentation is easily verifiable to prove the diagnoses being reported. They would rather take a 'hit' in the DRG payment now, than be audited & loose the entire payment due to not enough documentation of a certain diagnosis. We used to have to 'match' the CDI's DRG & if it didn't match what they came up with we would discuss the chart & show them any CC's that proved why we coded the way we did.  CDI specialists are NOT coders & they weren't always right, but in instances where there were 2 contrasting/comparable diagnoses etc.. the CDI team was very helpful in determining the principal reason that brought the patient to the hospital & what condition was the main focus of treatment. If the CDI specialists @ your facility are just sitting behind cubicles & not directly on the floor talking w/Dr.'s & reviewing records then I, personally, don't feel it's working properly.


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## mommacode (Aug 18, 2014)

My other question is, if a condition is documented in the record that isn't supported clinically, should it just be left out without verification with the provider?


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## mommacode (Aug 18, 2014)

What actually happens at my facility is the CDI attempts to code the chart. Just slapping on codes. Then it goes to the coder who has to sort through everything that was coded by the CDI and correct it all and prepare necessary queries that should have been initiated by the CDI. Then the coder must reconcile with the CDI and get her permission on whether codes can be changed and queries can be sent. Which wouldn't even have been an issue if the cdi had done her job in the first place.


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