May 13, 2011 | | Comments 4
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Books a CDI specialist shouldn’t be without

I had the pleasure recently of working with a fantastic group of medical coders. We shared many great stories and laughed about our

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various adventures in the field of documentation integrity. And then we started to talk about reference books we can’t live without. Yes, my inner nerd does periodically come out to play, and I found myself becoming envious. It seemed like coders had better books.

When I first started work as a CDI professional, I was given a notebook, a CC/MCC pocket reference guide, and a card with normal lab values. As I became more knowledgeable and realized how much I didn’t know, I started to print out copies of Coding Clinics and starting reading and re-reading the Official Guidelines for Coding and Reporting. That was the total extent of my reference materials.

Eventually, I found my DRG Expert. I love my DRG Expert and I don’t go anywhere without it. The coders were amazed by how quickly I could look up DRG’s without using an encoder. I felt like a Chinese mathematician using an abacus to solve difficult equations. That capability didn’t come easy, however. It took years of work. And like anyone else, I still use an encoder on occasion.

A CDI specialist (especially a reference geek like me) cannot live on Coding Clinic, Official Guidelines, and The DRG Expert alone. You can’t be expected to know everything, that is why it is important to have a resource where you can easily find the information you need. I encourage CDI nurses to obtain those resources needed to assist them in their daily work. Hospitals may not be willing to pay for resource materials (shame on them) so, consider buying one copy for the department to share, or invest in one book a year.

Sylvia and Glenn sign copies of the CDI Specialists' Guide to ICD-10 during the 2011 ACDIS Conference.

Since those early days, I have found a new wealth of helpful references through ACDIS. The Clinical Documentation Improvement Specialists Handbook, Second Edition by Marion Kruse and Heather Taillon is fantastic as is The Physician Queries Handbook, by Margi Brown, James Kennedy, Marion Kruse, and Lynne Spryszak. (I’ll also mention the newly released Clinical Documentation Improvement Specialsit’s Guide to ICD-10 that I worked on with Glenn Krauss, not to toot my own horn but because CDI specialists need to start learning about ICD-10 as soon as possible. Well, that and ACDIS Assistant Director/Book Editor Melissa Varnavas would kill me if I didn’t mention it!)

Resources and reference materials need not come only from books. Don’t forget about all the great resources in the ACDIS Forms & Tools Library, too. At any rate, if you are in doubt on what books to buy don’t worry, just ask a coder or fellow ACDIS member to recommend a good one!

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shoffman About the Author: Sylvia Hoffman, RN, is a CDIS in Tampa Florida. She has been a nurse for more than 20 years and enjoys writing, painting, and travelling.

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  1. If you had to pick one of your books to start, which one would you go with? I am fairly new to the role of CDI. I have had experience as case manager, clinical coder, performing medical reviews, and 14 years of clinical patient care experience I find myself at loss sometimes when it comes to some of the disease clinical indicators & forming Query’s. It’s getting easier as I go but I would like to gaet a reference I can take with me out on the units. Please advise? Thanks RY

  2. My CDI Pocket Guide by Dr. Richard Pinson and Cynthia Tang has been well worth the investment!! It fits perfectly into my rolling bag pocket.

    And I do believe it is the featured book for this week on HcPro! And no – I am not receiving anything for this endorsement. I am grateful for the resources it provides!

  3. Thanks for the feedback

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