Journal excerpt: Familiarizing yourself with coding guidelines

From the ACDIS CDI Blog

Because every chart is coded before being sent to payers, it’s important that CDI specialists have a working knowledge of code sets and coding rules. The inpatient prospective payment system (IPPS) final ruling, traditionally updated annually, has been changed to update twice a year on April 1 and October 1 beginning April 1, 2022. When reviewing a medical record, CDI specialists are making sure criteria for code assignment is met, diagnoses are clinically valid, and the documentation meets all other coding and reporting guidelines.

Before diving into the ICD-10 code set and getting to know the most recent IPPS ruling, CDI specialists must familiarize themselves with clinical criteria and understand how they relate to the associated codes.

“While I was developing the Orientation Calendar for New CDI Training, I had to begin with the most commonly seen diagnoses and their associated clinical indicators along with any applicable disease pathophysiology for each body system,” says Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor at HCPro in Middleton, Massachusetts. “Onboarding success is best achieved when the training regarding clinical, coding, legal, and compliance is delivered in layers. Education should begin with the basics and add the next layer of training to each of the three categories. You want to layer new concepts on top of the old.”

“You need to ingrain the diagnosis definitions to memory first,” echoes Dana Walker, MSN, RN, CCDS, educator of clinical documentation excellence at Novant Health in Winston-Salem, North Carolina. “They’ll eventually need to know DRG structure, CCs and MCCs, and the importance of how you move to a surgical hierarchy area, but it’s not the most important thing for those new CDI specialists. They don’t need to know all the ICD-10 coding conventions, but they need to understand when starting off that the conventions are there and ingrain them gradually over time, building upon the clinical knowledge.”

Though new CDI specialists don’t need to worry much about memorizing codes right from the start, they should still review this information and become at least mildly familiar with its nuances.

“Part of our training is going over the current version of ICD-10 guidelines,” says Walker. “We take the time to go over that when they start, and then go over it again later when they’re deeper into their training.”

As a CDI specialist grows, the codes and guidelines become more internalized and new learning can begin to build off of the basics. Once a specialist has become more seasoned and is getting the hang of CDI, they then need to familiarize themselves with specific codes and begin incorporating them into their mental library.

When starting to pull coding practice into daily tasks, there are certain codes that new specialists can expect to focus on. For prioritizing new code learning, diagnoses facing the most denials are a good place to start, as they will be a big review focus for many CDI programs.

“These are the charts where we are performing clinical validation 100% of the time,” says Walker. Respiratory failure, sepsis, and severe protein-calorie malnutrition are a few of the universal problem diagnoses that lead to high denial levels for most facilities. Because of this, they are a good place to start when becoming familiar with coding guidelines. Though these three diagnoses are seen commonly across all organizations, a new CDI specialist should also understand which other diagnoses are most frequently denied within the organization.

“Also take note of things that are quality focus points for your facility, such as readmissions,” Walker says. “Heart failure readmissions are a focus for our organization, so we pay close attention to them, meaning new CDI specialists should become comfortable with them because we want to make sure we get these right.”

Facilities often have workflow tools available that can help with training. Most CDI programs utilize encoders, or CDI software programs that assist with code assignment. While encoders should be used as a tool to assist and not heavily relied upon, they can aid in learning the coding guidelines.

“Many of these programs have coding and CDI resources built in that can help you familiarize yourself,” says Walker. “The ACDIS website is also a great resource if you don’t have those programs built in.”

Resources not only take the form of virtual or print tools but can also include knowledgeable colleagues.

“Foster and maintain a friendly and productive work relationship with your coders, because there’s so much they can teach you,” says Coral Fernandez, RN, CCDS, CCS, CDI auditor and educator at Baptist Health System in Louisville, Kentucky. “New CDI professionals should seek to learn everything they can from their coders. […] We each have our own point of view, and where we meet in the middle is where the CDI magic happens.”