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HIM’s Role in Healthcare Security and Privacy – HIM Scene

Posted on November 30, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

One of my go-to experts on healthcare privacy and security is Mac McMillan, CEO and Co-Founder of CynergisTek. He’s built a really great company that focuses on privacy and security in healthcare and he’s a true expert.

While at AHIMA 2016, I talked with Mac about the role that HIM plays in healthcare privacy and security. We also talk about where healthcare privacy is heading and which part of healthcare privacy and security doesn’t get enough attention. I also asked Mac to make a big 20 year prediction on what will happen with privacy and security in healthcare.

Check out our interview with Mac McMillan, CEO and Co-Founder of CynergisTek:

We shot a number of other videos at AHIMA 2016 which we’ll be posting shortly. If you enjoyed this video, be sure to Subscribe to Healthcare Scene on YouTube and watch our full archive of Healthcare Scene interviews.

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Will Medical Coders Be Needed in the Future? – HIM Scene

Posted on October 26, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

After spending time with so many HIM professionals at the AHIMA Annual conference, I’ve come back thinking about the future of medical coders. No doubt, many HIM professionals are moving well beyond medical coding into other areas such as healthcare analytics, clinical documentation improvement (CDI), EHR optimization, and much more. However, there’s still a massive need for high quality medical coding and the HIM professionals that provide that service.

As we look into the future, the techie in me feels like medical coding should be automated. Why are we paying people to do medical coding? Why can’t that be automated and be done by robots? It’s not like medical coding is a particularly fun job. I’m sure there are some times it’s fun working on unique cases, but it can be quite monotonous and tedious. Why not have a computer do it instead?

What I’ve learned over the years is that medical coding is more art than it is science. Certainly there are some clear cut cases where it’s basically science. However, a large part of what a coder does isn’t set in stone. There’s some artistic licence if you will, or at least some interpretation that has to happen in order to code a visit properly. Computers aren’t good at interpretation, but humans are.

The other reality is that doctors don’t produce perfect documentation. If they did, then we probably could code a robot to code a patient visit. Since there are nuances to every physician’s documentation, we’re going to need humans that interpret those nuances as part of the coding process. I don’t see this changing in our lifetimes.

One word of caution. Many people fall into the trap that we need automated robot coding to be perfect for it to accepted. That’s just not the case, because human coders aren’t perfect either. In fact, there’s some research that human coders aren’t as good as we thought they were at coding, but I digress. The reality is that automated coding just has to be better than humans, it doesn’t have to be perfect. Even with this said, I don’t see it happening for a while.

What we do see happening now is a collaboration between humans and computers: computer assisted coding. While we don’t have to worry about computers replacing humans in medical coding, we do need to focus on ways that technology can make the work humans do better. That’s a powerful concept that we’re starting to see happen already.

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Integrating CDI Efforts Across Inpatient and Outpatient – HIM Scene

Posted on October 19, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

One of the main topics HIM professionals have been discussing for a couple years is around CDI (Clinical Documentation Improvement). These programs have taken all sorts of shapes and sizes. Some are completely human driven. Others are largely tech driven, but most are a mix of the two. In fact, most CDI programs have gotten quite sophisticated and are really impacting the bottom line of healthcare organizations.

While most healthcare organizations realize that there are benefits to CDI, most of them have restricted these programs to the inpatient environment only. This was illustrated to me really well when I ran into a transcription vendor from India. It was his first time attending AHIMA and he was considering new areas of business including CDI. When we talked about CDI, his first comment was that he’d only ever seen CDI in hospitals, not in the ambulatory world.

While this is the case today, one HIM expert at AHIMA told me that one of the next big frontiers for CDI is going to be outpatient CDI. She went on to tell me that it’s fertile ground that could really benefit every healthcare organization. However, she also suggested that there shouldn’t be two CDI programs: 1 for inpatient and 1 for outpatient. Instead, CDI should be an integrated effort across inpatient and outpatient.

Clinical documentation improvement is only going to become more important in healthcare. Certainly, most CDI projects were started as a way to improve reimbursement. That’s a good goal and a benefit of a high quality CDI project. However, over time CDI is going to become even more important to an organization’s value based reimbursement efforts. In fact, if your clinical documentation isn’t accurate your reimbursement will really suffer. How can you keep a patient healthy if you’ve documented the wrong information for a patient?

How is your organization approaching CDI? Are you doing CDI in both inpatient and outpatient?

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Looking Forward to #AHIMACon16 – HIM Scene

Posted on October 12, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

As we prepare to head to the 2016 AHIMA Annual convention (see our full list of conferences we attend), we’re excited to talk about how we’re planning to expand HIM Scene to include as many HIM voices and perspectives as possible. HIM Scene will still be hosted here on Hospital EMR and EHR and will still have its own email list where HIM professionals can receive great HIM related content from thought leaders across the industry. However, we’ll be using HIM Scene to share a wide variety of people and perspectives.

The HIM industry is an amazing group of devoted people and that really comes through at every AHIMA annual convention I attend. Plus, HIM has a lot more influence than many people realize. So, we’re happy to do what we can to raise the voices and perspectives of HIM professionals here at HIM Scene.

Looking forward to the AHIMA Annual convention next week in Baltimore, we’re excited to learn about a number of important topics. Here are a few we’ll be sure to report on in future HIM Scene posts:

ICD-10 – A year after implementation, I’m really interested to hear the real stories of how ICD-10 has impacted healthcare organizations for good and bad. I bet there will be a lot of stories that haven’t been shared. I’ll also asking the HIM professionals I meet what they think the impact of the end of the ICD-10 grace period will have on healthcare. I wonder how many will have stories of ICD-10 improving care versus stories of ICD-10 for reimbursement.

Information Governance – This is an eternally hot topic in HIM, but it always continues to evolve. This is particularly true as records have gone electronic. This year I wonder how many people have been involved in some sort of health data sharing project. Information governance can get pretty tricky as healthcare organizations start to share data with each other electronically.

HIPAA Privacy and Security – A really hot topic given all the HIPAA breaches and ransomware incidents in healthcare. I’m sure I’ll find a number of HIPAA privacy officers that will share some good insights into how they’re dealing with these security and privacy challenges. I’m afraid many of them will give me exasperated responses about how their leadership isn’t taking it serious enough.

Informatics – I’ve been really intrigued with HIM’s role in healthcare informatics. Once you dive in, it makes since why HIM would be involved, but I don’t think most people saw that at first. What’s also been interesting to watch is many HIM professionals who’ve kind of shunned their involvement in healthcare informatics. We’ll see if many are still in that position or if most HIM professionals are starting to embrace and participate in the informatics efforts of their organizations.

What hot topics will you be looking for at the 2016 AHIMA Annual Convention? The AHIMA 2016 theme is to “Inspire Big Thinking to Launch Our Future.” We’ll be sure to report back any big thinking we hear from people we meet.

ahima-2016

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Managing Health Information to Ensure Patient Safety

Posted on August 17, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

Electronic Medical Records (EMRs) have been a great addition to healthcare organizations and I know many would agree that some tasks have been significantly improved from paper to electronic. Others may still be cautious with EMRs due to the potential patient safety concerns that EMRs bring to light.

The Joint Commission expects healthcare organizations to engage in the latest health information technologies but we must do so safely and appropriately. In 2008, The Joint Commission released Sentinel Event Alert Issue 42 which advised organizations to be mindful of the patient safety risks that can result from “converging technologies”.

The electronic technologies we use to gather patient data could pose potential threats and adverse events. Some of these threats include the use of computerized physician order entry (CPOE), information security, incorrect documentation, and clinical decision support (CDS).  Sentinel Event Alert Issue 54 in 2015 again addressed the safety risks of EMRs and the expectation that healthcare organizations will safely implement health information technology.

Having incorrect data in the EMR poses serious patient safety risks that are preventable which is why The Joint Commission has put this emphasis on safely using the technology. We will not be able to blame patient safety errors on the EMR when questioned by surveyors, especially when they could have been prevented.

Ensuring medical record integrity has always been the objective of HIM departments. HIM professionals’ role in preventing errors and adverse events has been apparent from the start of EMR implementations. HIM professionals should monitor and develop methods to prevent issues in the following areas, to name a few:

Copy and paste

Ensure policies are in place to address copy and paste. Records can contain repeated documentation from day to day which could have been documented in error or is no longer current. Preventing and governing the use of copy and paste will prevent many adverse issues with conflicting or erroneous documentation.

Dictation/Transcription errors

Dictation software tools are becoming more intelligent and many organizations are utilizing front end speech recognition to complete EMR documentation. With traditional transcription, we have seen anomalies remaining in the record due to poor dictation quality and uncorrected errors. With front end speech recognition, providers are expected to review and correct their own dictations which presents similar issues if incorrect documentation is left in the record.

Information Security

The data that is captured in the EMR must be kept secure and available when needed. We must ensure the data remains functional and accessible to the correct users and not accessible by those without the need to know. Cybersecurity breaches are a serious threat to electronic data including those within the EMR and surrounding applications.

Downtime

Organizations must be ready to function if there is a planned or unexpected downtime of systems. Proper planning includes maintaining a master list of forms and order-sets that will be called upon in the case of a downtime to ensure documentation is captured appropriately. Historical information should be maintained in a format that will allow access during a downtime making sure users are able to provide uninterrupted care for patients.

Ongoing EMR maintenance

As we continue to enhance and optimize EMRs, we must take into consideration all of the potential downstream effects of each change and how these changes will affect the integrity of the record. HIM professionals need prior notification of upcoming changes and adequate time to test the new functionality. No changes should be made to an EMR without all of the key stakeholders reviewing and approving the changes downstream implications. The Joint Commission claims, “as health IT adoption becomes more widespread, the potential for health IT-related patient harm may increase.”

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

Value Based Reimbursement: Another Challenge for HIM Professionals

Posted on August 3, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

How many times have you heard something along these lines: “HIM professionals must stay relevant and current with the continuous healthcare changes.” I must sound like a broken record to my team but it is absolutely true! HIM professionals provide the bridge between clinical data and reimbursement methodologies through CDI, coding, documentation integrity, and health data analytics to name a few. It has been proven time and time again that these HIM skills are vital to healthcare organizations but these skills must also be adapted and be put to good use each time a new guideline or rule is introduced.

Value-Based Reimbursement is an area that continues to grow with the push for quality patient outcomes and healthcare savings with potential penalties for excessive costs and poor quality of care. Reimbursement incentives that are tied to quality of care make perfect sense and HIM professionals need to take the plunge into these initiatives. By marrying departments and cross-functioning teams, we are able to generate proactive data and improve performance.

At my facility, I oversee the HIM department as well as the Quality department because we work closely together and will continue to have an even closer relationship throughout healthcare reform. This is becoming very common in the industry.

In this roundtable article for the Journal of AHIMA, we each outlined how we are bringing HIM to the table for Value Based Reimbursement initiatives and maximizing the tried and true skills of HIM professionals.

I have said it before and I will continue to say it: Always keep your finger on the pulse of healthcare and stay relevant by taking on these new challenges!

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

Are We Outgrowing HIM Systems?

Posted on July 15, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

We have changed and adapted to a rapid influx of electronic medical records and data over the last several years and it’s no surprise that some systems have struggled to keep the pace. Electronic medical records (EMRs) are in a state of constant revision to make sure patient care, clinical functionality, and data security measures are keeping up with our needs. It seems there are software application solutions or enhancements to almost every task we do in healthcare and these systems are also constantly evolving.

I don’t know of any healthcare application system or workflow that has remained static year over year and because of this, it is important for us to stay on top of vendors and keep an eye on current and future needs of HIM workflows. Clinical Documentation Improvement (CDI) is one of those areas that has been evolving since it first came on the scene and it is currently undergoing yet another face-lift. We realized there were many revenue opportunities hiding within inpatient clinical documentation and found that we could maximize reimbursement with a little detective work and physician education along with sophisticated software tools. Many are exploring the idea of CDI for outpatient levels of care. This means we will need software applications, interfaces, and expanded CDI workflows to extend these opportunities to outpatient documentation. Have you thought about what you will need from your vendors to adapt or upgrade current systems and how much will need to be budgeted for?

As we work to implement computer assisted coding (CAC) programs, we see opportunities to increase coder and CDI productivity and capture even more quality documentation by using discrete EMR data to our advantage. But are these CAC systems ready to be pushed to the limits to enter unchartered waters? I personally do not have a CAC success story to tell as of yet, but I am exploring the options and hoping that these systems have matured more than when we first explored them a few years ago.

That’s the beauty of technology in healthcare; if a product does not meet your needs, there may be other options already on the market or rapidly developing new technologies on the horizon. A vast amount of data may be held hostage in our systems if we do not maximize our EMRs and applications and set our standards high in a quest for knowledge. We can’t rely 100% on technology to dictate what we do which is why we need to be the visionaries and demand more from our systems in order to accomplish new and exciting things in HIM.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

The Cost of Encouraging Patient Engagement

Posted on June 15, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

We all know that healthcare providers want to encourage patient engagement to ensure patients have the information they need to manage conditions and share information with other providers. There has been a longstanding push for the adoption and maintenance of personal health records for many years to give patients the power to share and disseminate information wherever it is needed. We have seen a remarkable new interest in this with Meaningful Use and population health initiatives. Since HIM professionals are charged with maintaining and producing legal copies of records, we are aware that the tasks surrounding these processes can be very expensive. This is especially true if any of the tasks are not handled properly and breaches of protected information occur.

My concern is that lately I have heard many discussions that are pushing for more access yet with fewer costs to patients to encourage patient engagement. Some are even pushing for patients to have “free” access to records- paper or electronic. Don’t get me wrong, I am a huge proponent for patients having copies of their records and I personally keep copies of my own records. The Office of Civil Rights (OCR) recently published further guidance on charging for records. In a nutshell, the OCR says: “copying fees should be reasonable. They may include the cost of labor for creating and delivering electronic or paper copies; the cost of supplies, including paper and portable media such as CDs or USB drives; and the cost of postage when copies of records are mailed to patients at their request.” The OCR actually has the authority to audit the costs of producing records if they feel your organization is violating this patient right and overcharging for release of information.

Living in a state such as Florida where the state law has allowed facilities to charge up to $1 per page means most facilities have charged $1 per page without blinking an eye. The latest OCR guidance has led to questioning if that amount is actually “reasonable” or true to cost. Afterall, HIM professionals must use expensive systems, supplies, and labor costs to produce these records. Many organizations have outsourced release of information functions (another cost) but it is still the responsibility of the custodian of records to oversee the processes for compliance.

That being said, it is beneficial for HIM departments to evaluate the expenses and methods used to produce records as technologies and laws change. Dr. Karen Desalvo of the Office of the National Coordinator (ONC) strives to lead the EMR interoperability movement. At the top of the ONC’s list of commitments is consumer access to records. HIM professionals should continue to assist in the quest for interoperability and electronic data sharing at the notion of patient engagement. We must lead patients to use EMR patient portals and facilitate the efficient electronic data sharing among healthcare providers. We must be creative in lowering overhead costs to produce and maintain the records in order to ensure costs are affordable for healthcare consumers. There will always be costs associated with this important task, whether on the provider’s end or the patient’s end, just as costs are incurred with most services or products in every industry.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

ICD-10 Check-Up

Posted on May 13, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

It’s hard to believe it has been seven months since we implemented ICD-10 in the US. We talked about this subject and planned for so many years and now it feels like second nature. Looking back, I would label the implementation mostly successful and smooth. Would you say the same?

If you’re like me, you have forgotten some or most ICD-9 codes and have a nice repertoire of ICD-10 diagnosis codes swimming around in your head daily. At least memorizing the beginning of a code is helpful when you only need to search the encoder for the fourth through seventh digits of the code to further specify laterality and detail.

Conducting an external audit on ICD-10 coded accounts at this point is a good idea to make sure coders are accurate with the new code set. It’s important to watch for any trends in DRG shifts that may be attributable to ICD-10. If claims data for the past seven months have not been reconciled with expected reimbursement, now is a good time to be reviewing for coding and billing accuracy.

We were promised more specificity with ICD-10 and I believe we have somewhat achieved that. There are still opportunities to improve physician documentation and gather more detail in order to assign the correct codes. For the most part, I believe physicians have been affected by HIM teams bringing awareness to specific documentation and education on what is needed for ICD-10 coding and billing. ICD-10 has not turned out to be the burden that everyone was initially so reluctant to; at least from my experience.

In the blog post I wrote soon after ICD-10 implementation, I mentioned that coder productivity was a big issue to watch for with ICD-10. With sophisticated coding tools, thorough training, and skilled coders, the productivity impact has been real but not nearly to the extent some HIM managers were bracing for. We are starting to see coder productivity come to a manageable level that will probably be the norm for the foreseeable future.

I’m happy to report that I feel confident in ICD-10 as our designated code set and based on peer input, I think others will agree. The specificity was much needed after many years of vague or catch-all codes. This paves the way for better data reporting and thus more quality information resulting in better disease management. Accurate reimbursement is an obvious bonus as well.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

Can HIM Professionals Become Clinical Documentation Improvement Specialists?

Posted on April 21, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

Most acute care hospitals have implemented a clinical documentation improvement (CDI) program to drive appropriate reimbursement and clarification of documentation. These roles typically live (and should live) within the HIM department. Clinical Documentation Specialists (CDS) work closely with the medical staff and coders to ensure proper documentation and must have an understanding of coding and reimbursement methodologies along with clinical knowledge.

Certain aspects of the CDI or CDS role require in-depth clinical knowledge and experience to read and understand what documentation is already in the chart and find what is missing. Some diagnoses may be hiding in ambiguous documentation and it is up to the CDS to gather consensus from the medical staff to clarify through front-end queries. There are many tools available to assist in this process by creating worklists and documentation suggestions based on diagnosis criteria and best practices. The focus of CDI is not entirely on reimbursement, although it is a nice reward to receive appropriate reimbursement for the treatment provided while obtaining compliant documentation for regulatory purposes.

Determining or changing the potential DRG prior to discharging a patient provides a secondary data source for many healthcare functions such as case management, the plan of care, decision support, and alternative payment models. For these reasons, a CDS must know the coding guidelines for selecting a principal diagnosis that will ultimately determine the DRG.

Inpatient coders also have the foundational skills to perform this role. Coders and HIM professionals are required to have advanced knowledge of anatomy and physiology, pharmacology, and clinical documentation. Therefore, to answer my original question “Can HIM professionals become Clinical Documentation Improvement Specialists?”, the answer is absolutely. But I will say that it depends on the organization as to whether nursing licensure and clinical experience is required in the job description.

Some organizations have mixed CDI teams consisting of coders and nurses while others may allow only nurses to qualify for this role. The impact of who performs the CDS role in the CDI program all lies in the understanding of the documentation, knowledge of coding guidelines, and detective work to remedy missing or conflicting documentation.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.