Symposium Spotlight: Outpatient CDI and coding collaboration

Editor’s note: Deanne Wilk, BSN, RN, CCDS, CCS, and Melissa Maguire, BSN, RN-BC present “How CDI and Coding Can Travel Together in the Outpatient Realm: Goals and Initiatives,” on Day 1 of the ACDIS Symposium: Outpatient CDI. This year’s Symposium takes place November 8-9, at the Hilton Orlando Lake Buena Vista—Disney Springs area. To see the complete agenda, click here. To register, click here.

ACDIS: What does your outpatient CDI program focus on?
Wilk: Our initial focus was on the physician office setting particularly on family practice, internal medicine, cardiology, and neurology

ACDIS: Who performs the outpatient coding function?
Wilk: We really looked for CDI professionals who had at least two years’ experience, a CDI-related certification, and nursing credential. We started with three outpatient CDI-specific staff and all ambulatory coders who were relevant to those service lines. We hold regular coding and CDI educational sessions similar to those which might be deemed best practice on the inpatient side.

ACDIS: What are the most difficult outpatient coding concepts that CDI professionals struggle with?  
Wilk: Really, in my opinion, the biggest challenge comes from understanding the differences in the coding systems and the rules governing those code assignments. While CDI professionals working on the inpatient side may find the biggest obstacles in learning about ICD-10-CM/PCS, on the outpatient side they not only need to know that coding system but also the ICD-10-CM outpatient coding guidelines and the Current Procedural Terminology code set.

Alternatively, from the coders perspective even those who may have a number of years’ experience could struggle with concepts of clinical validity and documentation support for coded diagnoses.

Ultimately, having a unified coding and CDI message, along with collaboration between these departments helps with physician engagement in establishing consistency in documentation, billing, and educational foundations.

ACDIS: Fun question: Would you prefer a romantic vacation in Paris or family getaway in the mountains? 
Wilk: Family “glamping” getaway in the mountains!