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Question: Which resources are useful in the daily workflow of clinical documentation integrity (CDI) specialists?

West Virginia Subscriber  

Answer: People working in CDI need to be able to navigate resources to make sure documentation is comprehensive and codes are reported correctly.

Folks can find information through government resources like the National Institutes of Health (NIH) guides for health or updates that agencies like the Centers for Medicare & Medicaid Services (CMS) or the Centers for Disease Control and Prevention (CDC) release.

Folks can look to peer-reviewed journals like the AMA’s Journal of the American Medical Association (JAMA) for information that may be clinically relevant. Organizations like the AAPC, the AMA, and the American Hospital Association (AHA) provide coding resources — like AHA’s Coding Clinic publication — that coders can rely on for education and clarity.

And don’t forget to go back to the source, using reference materials like code books. Sequencing guidelines are crucial because of the context they provide for a patient’s medical narrative, but also because government payers and commercial carriers are both looking closely at which codes are used and in which order, especially to spot upcoding or downcoding. Practices want to avoid being penalized for such transgressions, especially if they’re unintentional; and having a thorough understanding of sequencing guidelines is crucial to reporting diagnoses, especially chronic conditions or complications, correctly.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, ÐÇ¿ÕÈë¿Ú