Summer Reading: Stepping out on your own

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

‘Flying solo’

After a few trial runs, new CDI specialists should be given the opportunity to review records on their own. Before composing any queries during this initial stage, the manager or mentor should review a draft of the query proposed and provide feedback to identify any additional opportunities and compliance concerns, as well as to save the fledgling staff member from any potential physician ire due to a misplaced query.

Such feedback should reinforce concrete rules of the CDI road and should be supported by official rational from governing bodies such as AHA Coding Clinic for ICD-10-CM/PCS, Official Guidelines for Coding and Reporting, ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, or in-house policies and procedures.  Of course, mentors and managers should offer their expert opinions and tips on how to practice effectively, as well. This feedback should also offer the new staff member an opportunity to voice questions and concerns, and accelerate the learning process. This step in the process can continue until the new staff member and the preceptor agree that the new CDI specialist is functioning well independently and is comfortable “flying solo.”

Once the new staff member is on his or her own, continue communication with the inpatient coding team to identify any potentially misunderstood coding or sequencing rules. Many CDI programs have regular weekly or biweekly group meetings with the CDI and coding teams to discuss difficult cases and air any questions or concerns. Most programs also have policies in place for how to handle any CDI/coder mismatches in MS-DRG assignment.

Every artist, whether painting, singing, or sculpting, must practice and hone his or her craft. Every record review will give the new CDI specialist additional experience to help you perfect your craft as well. Reviewing the record and querying the physician doesn’t simply mean that you pull facts from the documentation. It means that you are critically thinking as you discover those facts.

You must identify what facts may be missing, what information must be linked, and where the facts are contradictory or lacking support. This requires skill and knowledge. You were chosen for this position because your professional experience provides you with many of the tools needed. But rarely do we find an individual who comes to the role with “a full bag of tricks.” To fill your bag, you must be open to guidance, direction, and constructive feedback.

Depending upon your situation, you may have many individuals who desire to support you or you may find but one. Find those mentors and use them to fill your bag of tricks. Ask questions, use your available resources, and learn with every record review you perform.

Editor’s note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.