YES CDI Specialist: Liaison between CDI and Coding

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, safeguard regulatory compliance, improve quality outcomes, and actively support accurate facility and physician reimbursement.

What is a CDI Specialist? The role of the CDIS

According to AHIMA, “Successful clinical documentation improvement (CDI) programs facilitate the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending, and medical research” (AHIMA, 2024).

The YES CDIS team applies the official 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. The Inpatient Coding and DRG Validation team at YES is responsible for coding inpatient encounters and validating DRG accuracy for our clients’ optimal reimbursement. The team’s focus lies in thoroughly examining medical record documentation and verifying the assigned diagnoses and procedure codes. If the documentation is not comprehensive, an extra step is taken. The team may initiate a physician query to clarify any ambiguities to assure the proper ICD-10-CM and PCS code assignment. This instance also provides the opportunity for accurate MS-DRG assignment.

Do you want to see the traits of a successful CDI Program? Then, check out this article next: Know Your CDI Data – Statistics and Trends Analysis for Successful CDI Programs

How Data analytics enables our partner’s growth

As YES CDI Specialists, we close the loop as liaisons and provide education to the facility coding staff and the CDIS staff related to coding and clinical documentation to ensure adherence to regulatory guidelines and compliance best practices.

The YES CDIS team, working in conjunction with the YES Data Analytics team, gathers and analyzes pertinent data related to documentation outcomes and trends. The data provides trends and potential outliers that assist our facility partners in identifying preventive and corrective measures. This analysis is done to continuously improve the overall clinical documentation process.

For more information on how YES can be your CDI Specialist, check out our Services page.