Book excerpt: Learning CDI takes time
By Sheila Duhon, MBA, RN, CCDS, A-CCRN, CCS
Many CDI specialists come from a purely coding background, while others who have a purely clinical background seek additional education in the coding realm and have attained certification in the field of coding. Regardless of the foundational background, CDI specialists need to gain knowledge and expertise in coding through daily learning.
Query development is a cornerstone of the CDI process. Knowing when to query, how to query, whom to query, and the impact of the query on the final coded medical record is an aptitude that CDI specialists learn over time. Many factors enter into play when a CDI specialist is faced with a potential opportunity to glean additional specificity or granularity in the medical record. The mission of the specific CDI program will factor in. The culture of the organization will serve as an additional factor. Additionally, the specific medical record platform used in the organization affects the communication between CDI specialists and providers and is yet another factor in the query process. Therefore, a keen awareness of these elements will serve the CDI specialist well in determining query development opportunities and submission options.
When the mission of the CDI program has an emphasis on quality of care metrics and publicly reported data, CDI specialists must also possess a thorough understanding of the nuances and intricacies of the Agency for Healthcare Research and Quality (AHRQ) data.
Some CDI programs choose to stratify the CDI specialists into areas of expertise, with some members of the team having quality-focused assignments while others may have a more HIM and coding focus. Each approach is compelling on its own accord. It’s important to note that an overly broad approach and focus of the CDI reviews may lead to dilution of the CDI program mission. The CDI manager and leadership should always maintain the true intent of the program and align tasks accordingly to support that mission.
Editor’s note: This article is an excerpt from CDI Workbook: Investigating Complex Cases and Formulating Queries.