Note from the Instructor: Take a road trip this summer

by Laurie L. Prescott, RN, MSN, CCDS, CDIP

I recently taught a CDI Boot Camp at a large, multi-site organization, with attendees coming from CDI, HIM, and quality departments from four different sites. We began the week discussing the Official Guidelines for Coding and Reporting, moving through each Major Diagnostic Category (MDC), and talking about concerns related to code assignment and sequencing.

This discussion was very much a review for the attendees who hailed from the CDI and coding departments. The quality staff, however, coming from a variety of roles related to core measures, patient safety indicators, inpatient quality reporting, and hospital value-based purchasing, had continuous lightbulb moments.

One individual literally hit the side of her head and said, “This explains so much. How come we were not taught this before?”

After the first few days, I asked the quality department staff if they have ever told a coder or a CDI specialist that they “coded it wrong.” Almost every attendee raised their hand. I then asked the CDI specialists and the coders if they have ever been told they had coded a record incorrectly by an individual who had no understanding of coding guidelines. Every one of them raised their hands.

We discussed communications with providers, compliant queries, and practices of leading versus non-leading interactions when speaking to providers. Many of those who worked under the umbrella of quality spoke up to say that perhaps their discussions with providers had been leading. They never received education about how to compliantly query a provider for a diagnosis or how to query for removal of a diagnosis.

When we discussed sequencing new rules related to Chronic Obstructive Pulmonary Disease (COPD) and pneumonia, I noticed the quality folks looking at each other and making faces. I stopped the class to ask what was wrong. They responded by asking when the change occurred. When I told them late last year—per guidance from AHA Coding Clinic, Third Quarter 2016—they all sighed and one expressed frustration about not knowing about the change earlier. They had been struggling to understand why admissions for COPD suddenly sky rocketed. One simple discussion answered a question they had been struggling with for months. And, as an added bonus, they learned why the coders were sequencing these diagnoses as they were.

As the week progressed, we talked about the specifics of a number of quality monitors—discussing what populations were included, exclusions, and the adjustments applied to organizations related to reimbursement. Now the coders and the CDI staff were asking why they hadn’t been taught this material before. They began to understand why the quality department was so concerned about the presence or absence of specific diagnoses. The quality staff were saying, “we need your help.” There was a purpose to this class: to knock down silos, learn from each other, and support each other.

I often describe our efforts as a group of individuals driving down a five lane highway. We have coders, CDI specialists, quality staff, case managers/utilization review staff, and denials management all traveling in their own lane. But, we are all heading to the same destination. We are all working to bring success to our organization. We wish to be recognized for the high caliber of care we provide, and consequently reimbursed appropriately for the resources we lend to that effort. Documentation is the key to this successful road trip. The providers are working to navigate safely on this busy highway with only the drivers to direct them.

As we travel down this road, we often swerve into each other’s lane. Often we are forced to swerve because the provider looks for guidance from us, assuming we understand the driver’s manual for the other cars on the road. If we do not understand every other driver’s role and their specific manual, we cannot support each other. We need to keep all our vehicles traveling in the same direction at a safe speed and ensure that as the providers try to cross the road we don’t run them down. It is confusing to providers if the CDI specialists instructs them one way and the denial management team tells them the complete opposite. Then they seek clarification from the quality coordinator and get a third interpretation of the “rules.” The providers are bound to give up and just navigate in the bike lane, never making any actual progress.  

So, how do we learn to support each other? We need to step out of our comfort zones and spend some time with the other disciplines driving down that highway. We need to ask questions and answer other’s questions in return. We need to recognize that what we do affects the other’s work and work to support them. Large organizations often foster silos more than smaller organizations as they separate out the job functions more definitively. Often smaller organizations expect one person to wear a number of hats. Even though there are issues with overwhelming one individual, it also breaks down barriers.

Before you panic, I am not suggesting one person does it all. I am suggesting, though, that we intermingle a bit more, shadow different job roles, invite others to shadow us.

Take the road trip together—it’s more fun that way!

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, is a CDI Education Specialist at HCPro in Danvers, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.