By Melanie Endicott
The role of the clinical documentation improvement (CDI) professional is ever-changing. When CDI programs first started rolling out in the late 1990s and early 2000s, the focus was exclusively on acute care Medicare inpatients. The focus was merely on capturing complications and comorbidities (CCs) and obtaining specificity for a few focus areas, such as anemia, congestive heart failure, and pneumonia.
CDI programs today are morphing at a rapid pace. They are cropping up in settings such as hospital outpatient, physician offices, rehabilitation, and long term care. All payor types, not just Medicare, are being reviewed. And many programs are focusing on procedure documentation, for both ICD-9-CM and CPT, instead of solely on diagnoses. Even with ICD-10-CM/PCS implementation being more than a year away, many CDI programs are working on improving their documentation for ICD-10 purposes at present.
All of these changes require the CDI professionals to develop adaptation strategies to keep up with industry needs. One of these adaptation strategies includes a commitment to lifelong learning by attending conferences, reading textbooks and articles, networking with other CDI professionals, and taking continuing education courses. CDI professionals may consider earning a new credential to enhance their employment opportunities as well. Both coding and clinical skills need to be fresh and relevant.
ICD-10-CM/PCS is going to greatly change the role of the CDI professional. It is imperative that the CDI professional be trained in ICD-10 and understands the nuances of the new classification systems in relation to provider documentation. One way to prepare for ICD-10 is to compare the ICD-9-CM guidelines to the ICD-10-CM guidelines and identify areas that are different. There are many guidelines that are word-for-word the same in both sets of guidelines, however, there are some differences, which should be the area of focus for preparation.
One key area in ICD-10-CM that CDI specialists should be familiar with is the coding of acute myocardial infarctions (AMI). The use of the term “subsequent” in regards to AMI coding has changed from meaning the episode of care ICD-9-CM to meaning an additional AMI occurring during the acute phase (within 28 days) of the original AMI in ICD-10-CM. Also needed in the documentation is the wall involved (STEMI) and the coronary artery involved.
ICD-10-PCS is also going to bring about new documentation opportunities due to its increased granularity and specificity. CDI specialists need to remember ICD-10-PCS guideline A11, which states that it’s the coder’s responsibility to determine what the provider documentation equates to in ICD-10-PCS definitions. The coder, or CDI specialist, should not be querying the physician when the correlation between the documentation and the defined ICD-10-PCS terms is clear.
With all of the industry changes happening in healthcare, the CDI profession must evolve and adapt to stay ahead of the curve. CDI professionals should be lifelong learners, obtain a credential(s), and enhance their coding and clinical skills to pave a pathway to the future.
Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA (firstname.lastname@example.org) is senior director, coding and CDI products development at AHIMA. This article is a companion piece to her presentation, “Evolving and Adapting: The Changing Role of the CDI Professional,” at this year’s CDI Summit, held in Washington, DC.
"Evolving and Adapting: The Changing Role of the CDI Professional"
(Journal of AHIMA website),
August 06, 2014.