by Cynthia Tang, RHIA, CCS
From the very beginning, my business partner, Dr. Richard Pinson, and I have taught hospitals that coding specialists, not just nurses, can and should perform the CDI function. We have always included coders in our training sessions and advised hospitals to consider coders for the CDI role. Just as CDI specialists benefit from learning coding guidelines and principles, coding specialists can and should learn the clinical criteria.
As an employer, you may benefit from a team approach with both CDI Specialists and Coders able to identify documentation issues that will result in meaningful changes to the ultimate codes resulting in better data and reimbursement. Making the most of both areas of expertise results in a more efficient and productive CDI function.
How can a coder be an effective part of the CDI function?
- For coders, enhancing their understanding of diagnostic criteria and the disease processes will give them the ability to see all clinical relationships pertinent to the patient’s conditions.
- More knowledge of these diagnostic criteria and disease processes will alert coders to the need for queries when the documentation is lacking and will help the coder to prepare a more appropriate and effective query.
- More clinical skills will give coders more confidence as an equal partner in the CDI team and to provide their non-coding colleagues with additional insight into the intricacies and challenges of the coding systems.
- As a final benefit, coders with a firm grasp of the diagnostic criteria and disease process may decide to take the leap and advance their career as a CDI specialist.
The “CDI Bible”
When we created the CDI Pocket Guide 14 years ago, CDI was an emerging field and there was no reference tool available. Hospitals had to hire an expensive consulting firm, and even then, the educational materials were large three-ring binders containing hundreds of pages of information that was virtually impossible to reference.
The CDI Pocket Guide offers your CDI specialists and coders the tool they need to quickly and easily access the clinical definitions, diagnostic criteria, treatment considerations and specific challenges for the key clinical conditions encountered in the hospital. The CDI Pocket Guide has become the most highly respected unofficial source for authoritative CDI information. Thousands of coders and CDI specialists have come to rely on it, often telling us that it’s their “CDI bible.”
CDI Pocket Guide – Online
Same great content now available online! The CDI Pocket Guide – Online by authors Dr. Richard Pinson and Cynthia Tang is the same great proven resource used by coders, providers, and CDI professionals for over 13 years. Includes over 40 sample queries. Key reference and clear instruction ‘at your fingertips.’
Always up to date! Purchase today and receive unlimited access for one full year including notification of any updates or changes as they occur. Learn more here.
About the Author
Cynthia Tang, RHIA, CCS
Cynthia brings over 30 years of experience in health information management, coding and clinical documentation, and clinical resource management. For the past twenty years she has traveled to hospitals throughout the country to assess their processes for managing health information and clinical documentation and to provide her much-sought after expertise in redesigning operations to promote better patient care and hospital financial health.
Her focus is on workflow design and improving clinical documentation with a view to optimizing reimbursement, ensuring compliance, and improving quality and pay for performance measures.