Note from the instructor: It’s the principal of the matter

By Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC

My favorite part of teaching our Boot Camps are the discussions which take place as we move through the materials. CDI reviews vary from organization to organization and the regulatory guidance, including the Official Guidelines for Coding and Reporting and AHA Coding Clinic, often contains many shades of grey that lead to different interpretations, confusion, and frustration for those wishing to learn. This is particularly true regarding rules governing principal diagnosis sequencing. Sequencing, and identifying the working DRG, is a core function of CDI within the inpatient setting, and it’s one of the most difficult rules to learn.

Principal diagnosis selection so important that the Official Guidelines for Coding and Reporting has an entire section dedicated to it. Section II of the Guidelines is entitled “Selection of Principal Diagnosis.” When I receive questions about sequencing, I prompt the student to go back and read (and in many instances, re-read) these rules.

You can’t stop there and think you’ve learned everything there is to know about principal diagnosis selection, however. Coding conventions offer us guidance in the form of notes within the code set such as “code first notes.” The direction listed under adverse effect codes (T36-T50) which instruct us to code first the manifestation are a perfect example of this. And, of course, Coding Clinic offers advice related to sequencing as well. 

So, how does one learn all these rules and know how or when to apply them? Your encoder and software will likely help but you need to understand the underlying logic behind that system in order to input the right information. Because this is such an important topic, I’ve developed a number of suggestions for new CDI specialists including:

1. Review Section II of the Guidelines. It’s a quick read. Read it more than once and think of specific examples you see in your daily practice that apply to the situation. If you don’t understand the guidance, speak to your peers and leverage your resources from the coding department.
2. Learn to use the code books (Alphabetic Index and Tabular List): There’s a wealth of information within the code set, including the “code first” and “code also” notes that will assist you in understanding why certain combinations of diagnoses must be sequenced in a specific order. If the encoder leads you to a DRG that does not seem appropriate, try looking at the direction within the code set to better understand the guidance.
3. Ask coding professionals questions: When you’re reconciling with a coder and you reach a disagreement, ask the coder for the rule or Guideline that states the diagnoses must be sequenced in a certain way. Look up that guidance to better understand the application of that rule. Once you have looked up the guidance yourself, whether it be a Guideline, coding convention, or Coding Clinic, you can internalize that direction and learn how to apply it in similar situations within the future.
4. Stay up-to-date with AHA Coding Clinic: Coding Clinics are published quarterly by the American Hospital Association (AHA). You cannot memorize them all, but you should review new publications as they are released and have a comfort level in searching through the old publications for applicable advice.
5. Review confusing cases: I’m not a fan of meetings, but I do think every meeting should have a component of learning/education. One great addition to a meeting would be a review of scenarios that fall into the “grey zone” of guidance—meaning, those cases for which the guidance is left to interpretation. Everyone can review the cases prior to the meeting and then a lively discussion can ensue and everyone can learn something.
6. Ask for feedback: Let the coding staff know you are trying to learn and welcome their feedback and guidance. Most are willing to assist and send you guidance when they find a learning need.
7. Ask for help: It is okay to ask for help. I can’t count how many times I had to call a coder and how many times I still seek help if I’m confused or unsure. Before you reach for your phone, first investigate your sources and see if you can find the answer yourself. This exercise of investigation will reinforce the learning.

Finally, know you are not alone. The process of CDI review and sequencing diagnoses is not a simple one. If it was, we would not enjoy the challenge of being a CDI specialist. The fact we have something to learn every day is why we love the job.

Editor’s note: Prescott is the CDI Education Director at HCPro in Middleton, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.