by Richard D. Pinson, MD, FACP, CCS
As a result of the COVID-19 pandemic, many CDI nurses have been repurposed to clinical care and hospitals are relying on coding professionals to fill the CDI void. What must coders do to accomplish this task for their hospital?
Perhaps the most immediate need is acquiring more clinical information to recognize undocumented medical conditions for which there is strong clinical evidence (diagnostic criteria) that would prompt a CDI query.
This doesn’t require coding professions to study a ponderous medical textbook or recognize all the diagnoses in every MDC. Only about 50 specific medical conditions constitute 90-95% of the inpatient queries needed, such as systolic/diastolic heart failure, encephalopathy, respiratory failure, acute kidney injury, morbid obesity and the like.
In addition, the coding professionals’ query construction skills may need to be sharpened. To improve query composition and editing of templates, the hospital’s most experienced documentation specialist could offer examples and provide coaching for their coding colleagues.
While COVID-19 is the immediate precipitant of this opportunity, it may result in a permanent opening of this career path to non-clinical staff. Hospitals able to take advantage of their skilled coding staff and offer this opportunity for advancement will find a willing and able workforce at the ready.
Pinson & Tang CDI Pocket Guide
Libman Education offers many resources for coding and documentation specialists. Perhaps the most popular is the Pinson & Tang CDI Pocket Guide recognized by CDI professionals for over thirteen years as their “CDI Bible!”
The Pinson & Tang CDI Pocket Guide provides specific standardized query templates for the most common medical conditions as well as instruction on how to modify the template to fit the particular circumstances of the case in question.
A set of free standardized query templates is available for free on the Pinson and Tang website. Select “Resource” tab and search “Queries.”
About the Author
Dr. Richard Pinson, MD, FACP, CCS
Dr. Richard Pinson is a physician, educator, administrator, and healthcare consultant. He practiced Internal Medicine and Emergency Medicine in Tennessee for over 20 years having board certification in both. Dr. Pinson is a Fellow of the American College of Physicians and former Assistant Professor of Clinical Medicine at Vanderbilt, and has assisted hospitals as a physician consultant for the past ten years. Dr. Pinson’s personal understanding of the mindset of both doctors and managers allows him a unique vantage point from which to promote cooperation between physicians, hospital staff, and administrators toward achieving beneficial and practical changes.