Guest Post: Collaboration: Coding and me
by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
I realize that many of the faithful members of ACDIS are, indeed, coders, but most of us have a nursing background, so I’m going to give my two-cents on the coding/CDI specialist relationships from a nursing perspective and hope that the coders among us will forgive me.
The first thing and the last thing that coders and nurses need to understand is that nobody knows everything. If you remember a Venn diagram—yes, those big bubbles with the overlap in the middle that you learned in 7th grade math—and apply it here, we have the coding world, and we have the nursing world, and we have that great big space in the middle where we cross paths. Nevertheless, we also must bear in mind that there is space on the left and right where never the twain shall meet.
Both nurses and coders have studied anatomy and physiology, we all know medical terminology, and we all have some understanding of coding guidelines and principles. That’s where we meet.
But coders have studied coding, and they typically can code up to 30-40 charts or more per day with staggering precision. The average nurse doesn’t spend the time assigning CPT codes, or E-codes, or worrying about whether the femur fracture is of the head, the shaft, or the condyle part of the bone, the way coders do.
Likewise, the average coder has never been in the room with the hundreds or thousands of patients that the nurse has seen, has not personally observed or helped treat the signs and symptoms associated with the myriad medical conditions people can acquire, and does not have the in-depth knowledge of intricacies of medical management that nurses have.
When I first started as a CDI specialist, it took time for the coders to get used to me and what I could do for them—and to them. Because my orientation was bare bones and my preceptor was literally in the next state, I had to learn by mistake. And boy, did I make mistakes.
I can’t tell you how long it took me to grasp that hypertension in a patient with chronic renal disease codes out differently than it does for hypertension in the general population. I’m still embarrassed to admit that I nagged a coder to take a vascular ulcer as a CC on a patient with peripheral vascular disease because I didn’t understand how to apply the combination code.
It took persistence and patience but eventually the coders realized that not only was I a fast learner, but that there were some things that I could teach them. One coder was coding atrial fibrillation (AF) with rapid ventricular response (RVR) as ventricular tachycardia, which not only added CCs to the coding summaries, but drastically altered the dynamic of those charts. As a former cardiac care unit (CCU) nurse, I knew that AF with RVR is absolutely not “v-tach.” I argued my case, and even enlisted one of our electrophysiologists to help me explain the situation.
The electrophysiologist was able to verify that AF w/RVR is definitely not v-tach, and further emphasized that if v-tach were to be coded, it would completely change the treatment protocols he would have been expected to perform. By pressing the issue, I might have lost our facility some CCs, but I think I saved us a lot of heartache in future audits.
I have tremendous respect for the work that coders do. It pains me to see adversarial relationships between coders and nurses. Everybody wants to be right, especially if their work is going to be graded negatively if they’re not officially right. But some nurses are just determined to prove that they know more than coders—and vice-versa.
I really miss the days when I could just call a coder for a consult on a complex case while the patient was still in-house, and when the coder could call me to ask my take on a confusing chart they were coding.
It may be difficult for more experienced coders to understand the need for a CDI program when they have been sending back-end queries for years without help. So those CDI specialists who do have a nursing background may be in a situation where they need to prove their value—not by fighting with coders but by sharing our clinical expertise in a nonjudgmental manner.
We need to remember that everyone’s goal is an accurate, pristine chart, regardless of who gets credit.
I suppose there are some relationships that will always be sticky. Let’s just make this one stick.
Editor's note: Brown, at the time of the article's original response, was an independent CDI consultant based in Carrollton, GA. With experience in critical care, nursing education, disease management, case management, and long-term care, she has worked as a CDI specialist, educator, director, and consultant. She is a frequent writer on topics involving clinical documentation and published her own "The Case Manager's Quick Guide to Diagnostic Related Groups" in 2013.