Beyond the Bedside: From Coding Patients to Coding Charts

CMagill, BSN, RN

What Is Clinical Documentation?

Simply stated, "clinical documentation" refers to the information entered into a patient's medical record by the healthcare professional. While the data captured is specific to each patient, the components of the medical record are mostly universal. Below are some examples of documentation you will find in a medical chart:

Care Plans and Progress Notes
Diagnostic Studies and Treatment Plans
Height, Weight, and Allergy Information
Immunization Status
Past Medical History and Current Symptoms
Prescription Information and Medications Administered (during the inpatient stay)
Vital Signs

Multiple members of the healthcare team access and contribute to a patient's medical data, and it is important to ensure the documentation portrays a true illustration of the patient's state of health. This is where the Clinical Documentation Improvement (CDI) specialist comes in! The CDI specialist acts as a liaison between the healthcare provider and the coding team to promote precise documentation, which supports improved patient care and better billing practices.

Clinical Documentation Improvement (CDI)

The American Academy of Professional Coders (AAPC) describes CDI as "the process of reviewing medical record documentation for completeness and accuracy.” A CDI specialist, also known as a Clinical Documentation Specialist (CDS), often has both clinical and coding experience. The role of the CDS is to thoroughly review progress notes, imaging interpretations and lab values, historical and current diagnoses, consult and procedure notes, etc. – they look at all documentation which may be used to determine the condition of the patient as the hospital stay progresses. If a discrepancy is found, the CDS will work with the provider (who is ultimately responsible for the information contained in the patient's chart) to improve areas in the medical record where documentation may be lacking or to resolve any conflicting information.

What Is a DRG?

DRG stands for "diagnostic-related group,” a method used by Medicare and other insurance companies to pay the health system a specific rate for a patient's hospitalization. The DRG assigned to the encounter is influenced by several factors, such as the seriousness of the patient's current illness, previous or unresolved health complications that may be hindering the healing process, the amount of resources required to treat the patient, any procedures that are performed, the likelihood of the patient returning to his/her baseline status, and many others.

The CDS performs a concurrent review of the medical record, meaning the chart is reviewed while the patient is in the hospital, to establish a "working" DRG. Once the patient has been discharged, the coder will also perform a thorough review of the chart, resulting in the "final" DRG. In the end, the goal is for the DRGs identified by both the CDS and the coder to be in agreement. A matching DRG helps to validate several things:

The documentation in the medical record accurately represents the patient's condition.
The bill that will be sent to the patient will not include unnecessary charges.
The hospital will be reimbursed appropriately for the care provided to the patient.

A Non-Bedside Nursing Opportunity

Nurses who are looking to leave the bedside but do not wish to leave healthcare altogether may want to consider a position as a CDI specialist. Their clinical background provides several benefits, such as:

Knowing where to look for pertinent information
Identifying conflicting, incomplete, or missing documentation
An established rapport with other healthcare professionals
Familiarity with provider communication preferences

Certification Opportunities

Nurses love to continue learning, and they can become proficient in coding processes over time if this is not something they are currently familiar with. Organizations like The American Health Information Management Association (AHIMA) offer a wide range of certification opportunities. A few examples are:

Certified Coding Associate (CCA)
Certified Coding Specialist (CCS)
Certified Documentation Improvement Practitioner (CDIP)

The Association of Clinical Documentation Integrity Specialists (ACDIS) is another organization that offers certification opportunities for those who have achieved success in the CDS role. These organizations promote learning and growth in this field by bringing people together and sharing knowledge through conferences, forums, and podcasts.

Choosing to leave the bedside can be a difficult decision, and sometimes nurses are required to consider other options before they feel like they are ready. As a CDI specialist, nurses have a particularly important role, both as a patient advocate and as a valued member of the care team. Promoting accurate documentation is essential because we all know,