RN-Coding Documentation Specialist  - New RN-CDS credential from AACCA
Clinicians Learn Proper Documentation

Clinical documentation was prioritized by our industry advisors as one of the most important training topics affecting health-care organizations today. This training will provide a basic understanding and a good foundation for proper clinical documentation.
This CE certificate program will be useful for nurses, physicians, therapists, and other health-care professionals as well as other staff involved in documenting patient progress. This CE certificate program provided by SMRS | RN-Coder Network, an approved CE provider of the California Board of Registered Nursing. CEP#13482
Why is this career niche needed?

Clinical documentation improvement is a burgeoning career field that’s developed in response to the Centers for Medicare and Medicaid Services (CMS) Diagnostic-Related Group (DRG) system. This field really took off after implementation of CMS-DRGs in October 2007.

Briefly, the CMS-DRG system assigns an International Statistical Classification of Diseases and Related Health Problems (ICD-9) code to each inpatient diagnosis and procedure and groups the case into one of 745 DRGs. Each DRG is assigned its own relative weight and geometric length of stay. Relative weight is used to determine payment because all the diagnoses in any given DRG are assumed to use about the same degree of resources.

DRGs can be adjusted upward by including documentation of major and minor comorbidities, or by shifting the principal diagnosis to one that leads to reimbursement for a higher intensity of illness and more care required. Hospital administrators quickly realized that the diagnosis chosen affected a case’s DRG and reimbursement and that the DRG could be maximized with accurate documentation. Severity of illness and risk of mortality indicators impacting hospital and physician grading systems could also be modified by a more accurate medical record.
Enter the RN-Coding Documentation Specialist 

Getting specific -- Let’s see the effect of inaccurate codes.

A patient whose principal diagnosis is acute renal failure will fall into DRG 684, Renal Failure. If this patient also has signs of decompensating heart failure and the healthcare provider documents “CHF,” the hospital staff may expend time and resources treating this problem without it being reflected in the DRG. CMS expects the provider to indicate whether heart failure is acute or chronic, and whether it’s systolic or diastolic in origin. You explain to the healthcare provider that he must document the diagnosis as “acute on chronic systolic heart failure” to meet the CMS documentation standards. The DRG becomes 682, Renal Failure with Major Comorbidity, which indicates a higher severity of illness and a higher relative weight due to the increased resources needed to treat the patient.

The correct diagnosis provides a greater reimbursement and longer expected length of stay. The hospital is rewarded for diagnosing and treating the complicating condition when it’s properly documented, and the hospital is penalized when it isn’t.  

Another patient has surgery for an “irrigation,” which normally can’t be billed by the hospital. When you talk to the surgeon and learn that she actually performed an excisional debridement, then show her how to document that in the medical record, you’ve turned a medical admission into a surgical admission with a billable OR procedure.

Based on your in-depth knowledge of both clinical and coding standards, you’ll educate the healthcare provider about the standards and formulate queries or clarifications, written requests to correct or improve the documentation, when the notes in active medical records are unclear or incomplete.
Although hospital coders are permitted to pose queries retroactively when they’re working with the discharged medical record, the record is more likely to come under scrutiny when entries to the medical record, particularly those that may increase reimbursement, are made after the patient is discharged. In addition, the coder must hold the medical record for final billing until the query is answered, delaying payment to the hospital.

Clinical experience a plus!

Although some CDI programs employ coders as CDI specialists, you, as a nurse clinician, can offer a unique perspective with clinical experience to support your analysis of the medical record. Speaking the language of healthcare providers, you can communicate with them as fellow members of the clinical team. Looking at progress notes, consultant reports, medication records, lab values, and radiology reports, you draw on your nursing background to predict or anticipate the diagnoses of patients being treated, and use your knowledge of coding rules to help the healthcare providers choose the right words to describe the diagnoses in CMS-friendly terms. You also work closely with other disciplines such as nursing and dietary, whose documentation helps support healthcare providers’ diagnoses and queries.

Hospitals count on their RN-CDSs to protect them from Recovery Audit Contractors (RAC), which are Medicare-contracted companies looking to recoup money that’s already been paid to the hospital, and to help them maintain positive scores with grading agencies and government entities that evaluate hospitals for the public. Complete and accurate documentation lessens the likelihood of a RAC’s success.

As programs develop and healthcare reform takes shape, the scope of practice of the RN-CDS will continue to expand. Some hospitals have asked their RN-CDSs to formulate queries for core measures, hospital-acquired conditions, patient safety indicators, quality indicators, and any other areas that can be enhanced through good documentation. Compliant documentation that neither overstates nor understates the severity of illness and resource utilization is a critical tool in shielding hospitals and healthcare providers from allegations of Medicare fraud and waste.

A completely new coding system, ICD-10, becomes mandatory in October 2015 bringing a dramatic increase in the specificity of documentation CMS expects from healthcare providers. RN-CDSs will be invaluable in helping healthcare providers navigate the new requirements.  
Practical steps to a new career

While formal training isn’t usually required, you may reap great benefits from enrolling in a coding or RN-CDS program for nurses that helps you learn the language of coding. You should expect a structured orientation program from your hospital. 

RN-CDS Certification is Available from the American Association of Clinical Coders and Auditors

 At this time, the principal certification credential for nurses is through AACCA, the Association of Clinical
Coders and Auditors, which administers the RN-CDS credentialing exam to working CDI specialists. Additional information
on membership and certification can be obtained at www.AACCA.net   
An RN-CDS usually works standard business hours and earn salaries competitive with case managers and other hospital nurses who don’t provide direct care to patients. When you enter this field, you should be prepared to work independently with little or no daily supervision. You should also be self-paced and self-directed, extremely detail-oriented while understanding the big picture, able to manage and prioritize a shifting caseload, and comfortable with frequent change.
The career of an RN-CDS is demanding but the rewards are considerable. Are you ready for the challenge? 
  1. Jessup M, Abraham WT, Casey DE, et al. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119(14):1977-2016
  2. Bowman S, Smith PC, DeVault K, et al. Managing an effective query process. J AHIMA. 2008;79(10):83-88
  3. Centers for Medicare and Medicaid Services. Recovery Audit Program. 2012. http://www.cms.gov/recovery-audit-program/
  4. Robinson S. The art of physician communication. 2010. http://www.hcpro.com/content/253291.pdf
RN-Clinical Documentation Specialist is a growing profession for nurses, and is in need of trained Clinical Documentation Specialists. Are you new to CDI or a seasoned veteran? The RN-Clinical Documentation Specialist (RN-CDS) provides the nationa's only RN-Clinical Documentation Specialist CE certificate program dedicated specifically to Clinical Documentation Improvement and Integrity by nurses certified to do this work. The RN-CDS program addresses the evolving education needs of nureses that are inherent to the significant changes emerging in US healthcare, especially as they relate to the Medicare Severity-Diagnostic Related Group (MS-DRG), the Recovery Auditor Contracts (RAC), Quality initiatives, and ICD10 implementation. Our approach is evidence-based and combines engaging instruction with interactive case studies and resource materials developed specifically for nurses.
The RN-CDS Institute focuses on:
  • Clinical acumen & Explicit documentation
  • Medical Necessity
  • Coding guidelines
  • Compliance
  • Proactive preparation for the integrity regulatory agencies.
  • Basics of an effective CDI program Reporting and benchmarking Review of compliance organizations such as Office of Inspector General and Medicare Recovery Auditors and others
  • Understanding the Physicians and Nurses role in CDI
  • Importance of Documentation Checklists by Diagnosis & Severity
  • Understanding the Inpatient Prospective Payment System (IPPS)
  • Introducing MS-DRGs (Major -Complications /Co-Morbidity and Complications/Comorbidity)
  • Understanding MS-DRG and the impact on the Case-mix index
  • Introduction to the Uniform Hospital Discharge Data Set (how to select the principal diagnosis, secondary diagnoses, principal procedures and secondary procedures)
  • Understand what documentation is needed for problematic MS-DRGs
  • Understanding the relationship between coding and documentation
  • Practice case studies 
  • Nurses earn 8 CE contact hours per day (CA BRN CEP# 13482)
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