YES CDI Specialist: Liaison between CDI and Coding
The role of the YES Clinical Documentation Improvement (CDI) Specialist is to be a liaison and a partner. They compare the facility CDIS Medicare severity diagnosis-related group (MS-DRG) to the facility coder MS-DRG when there is a mismatch between the two MS-DRGs. The CDIS reviews the medical record concurrently for the appropriate clinical documentation and determines the substantiated MS-DRG. Furthermore, it is also our teams’ main goal to enhance the CDI review process and clinical documentation. We want to ensure the documentation deems the inpatient admissions as medically necessary; to safeguard regulatory compliance; to improve quality outcomes and to actively support accurate facility and physician reimbursement.
What is a CDI Specialist? The role of the CDIS
The CDIS applies the coding rules and guidelines to each review; this determines that the coding assignment is accurate and reflects the best clinical picture for the patient encounter. As a collaborator, and Director of Coding and CDI at YES, we make sure that comprehensive medical record documentation indicates the clinical treatment administered; and the assigned diagnoses as well as procedure codes. If the documentation is not comprehensive, an extra step is taken; there may be an opportunity for a physician query to clarify the clinical picture in order to assure the proper ICD-10-CM and PCS code assignment. This instance also provides the opportunity for accurate MS-DRG assignment.
How Data analytics enables our partner’s growth
As CDI Specialists and Liaisons, we close the loop and provide education to the coder and the CDIS; as it relates to coding and clinical documentation to ensure adherence to regulatory guidelines and compliance best practices.
The YES CDI team gathers and analyzes pertinent data related to documentation outcomes and trends. As a result, the data provides trends and potential outliers that our partners must identify for preventive and corrective measures. This analysis is done not only regarding the human resource, it is also emphasized on continuous improvement of the overall clinical documentation process.
For more information on how YES can be your CDI Specialist, check out our Services page.
