YES CDIS: Liaison between CDI and Coding
The role of the YES Clinical Documentation Improvement (CDI) Specialist is to be a liaison and a partner, to 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 medical record is reviewed concurrently for the appropriate clinical documentation to determine which MS-DRG is substantiated. It is also our teams’ main goal to enhance the CDI review process and clinical documentation in order to ensure inpatient admissions are deemed medically necessary, to safeguard regulatory compliance, to improve quality outcomes and to actively support accurate facility and physician reimbursement.
Coding rules and guidelines are applied to each review to determine 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, one of our goals is to make sure that comprehensive medical record documentation indicates the clinical treatment administered, and the diagnoses as well as procedure codes that are assigned. If the documentation is not comprehensive, an extra step must be taken, as there may be an opportunity for a physician query to clarify the clinical picture in order to assure that the proper ICD-10-CM and PCS code are assigned. This instance also provides the opportunity for accurate MS-DRG assignment.
How Data analytics enables our partner’s growth
As Liaisons, our goal is to 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. The data provides trends and potential outliers that our partners must identify for preventive and corrective measures to not only be applied correctly, but to be ensured effective. This analysis is done not only regarding the human resource, it is also emphasized on continuous improvement of the overall clinical documentation process.