By Cynthia Tang,  RHIA, CCS, CRC

From the very beginning, my business partner, Dr. Richard Pinson, and I have taught hospitals that coding specialists, not just nurses, can and should perform the CDI function. We have always included coders in our training sessions and advised hospitals to consider coders for the CDI role. Just as CDI specialists benefit from learning coding guidelines and principles, coding specialists can and should learn the clinical criteria.

As an employer, you may benefit from a team approach with both CDI Specialists and Coders able to identify documentation issues that will result in meaningful changes to the ultimate codes and reimbursement.  Making the most of both areas of expertise results in a more efficient and productive CDI function.

How can a coder be an effective part of the CDI function?

• For coders, enhancing their understanding of diagnostic criteria and the disease processes, will give them the ability to see all clinical relationships pertinent to the patient’s conditions.

• More knowledge of these diagnostic criteria and disease processes will alert coders to the need for queries when the documentation is lacking and will help the coder to prepare a more appropriate and effective query.

• More knowledge will give coders more confidence as an equal partner in the CDI team able to provide their non-coding colleagues with additional insight to the intricacies and challenges of the coding systems.

• As a final benefit, coders with a firm grasp of the diagnostic criteria and disease process may decide to take the leap and advance their career as a CDI specialist. 

When created the CDI Pocket Guide 14 years ago, CDI was an emerging field and there was no reference tool available. Hospitals had to hire an expensive consulting firm, and even then, the educational materials were large three-ring binders containing hundreds of pages of information that was virtually impossible to reference. 

The CDI Pocket Guide offers your CDI specialists and coders the tool they need to quickly and easily access the clinical definitions, diagnostic criteria, treatment considerations and specific challenges for the key clinical conditions encountered in the hospital.  The CDI Pocket Guide has become the most highly respected unofficial source for authoritative CDI information. Thousands of coders and CDS have come to rely on it, often telling us that it’s their “CDI bible.”