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 (Editor's note: For more information on clinical documentation improvement programs, see our Print article titled Working Hand-in-Hand, published in the November 2009 issue.)
Cathy Brownfield, RHIA, CCS, director of coding and auditing for HealthPort in Alpharetta, GA, admits that a coder's role in clinical documentation improvement (CDI) can be limited--unless she has direct access to the physicians with whom she works.
With that level of access, a coder well-versed in anatomy, disease processes and other aspects of health care can be an invaluable resource to CDI initiatives.
"If coders can apply their knowledge to the actual coding process, they'll know when they should be asking questions," explained Brownfield. "If the documentation is obscure or incomplete, the coder needs to be querying the physician."
Too many errors or inconsistencies make their way through documentation due to the unwillingness or reluctance of coders to point out a physician's mistake or oversight. Brownfield stressed that simply acknowledging the error--whether to a physician or to your coding manager--makes all the difference in the accuracy of the document.
"Just speak up," she urged. "Coders can identify these patterns--they are the ones looking at these records every day. So by taking it upon themselves to ask these questions, other people in the department become aware of what improvements need to be made."
Those improvements may be relevant to a particular case, or across the board in terms of a department's procedures. Over time, a good coder will learn the tendencies of particular physicians in documentation. The key is working with the physician to ensure that all conditions, diseases or other indications are ultimately covered in the final document.
Brownfield used the example of a (hypothetical) physician who tends to indicate sepsis in cases with fever and elevated white count. If she repeatedly queries only to have the physician rule out sepsis in their conversation, she knows she may need to talk to this doctor to establish the importance of documenting the ruling out of the condition so that not all cases will appear to be septic.
If that doesn't work, it's time to involve the coding manager. "Sometimes this will need to be taken further," Brownfield admitted. "Depending on the hospital, there may be a CDI program to manage issues just like these."
Rob Senior is managing editor at ADVANCE.
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