By Mary Butler
On the most widely used job search websites, listings for clinical documentation improvement (CDI) specialists typically look something like this:
Description: The clinical documentation improvement specialist provides support of clinical documentation improvement activities in an effort to support accuracy and quality in the patient records at Hospital X and to ensure that coded diagnoses are an accurate reflection of the patient’s clinical status and care.
Duties and responsibilities: Participating in education of members of the patient care team on documentation guidelines; electronically querying physicians/other providers regarding missing, unclear, or conflicting medical record documentation.
Licensure or certifications: RHIA, RHIT, BSN, RN, MD, or comparable. The following are preferred: CDIP, CCDS, CCS, and ICD-10 certification or designation.
There are two different types of healthcare professionals that can look at this description and envision it as a stop on their career path—coders and nurses. The answer to the question about just who can do this job the best, however, is at the crux of a professional rivalry that remains just under the surface on teams of CDI specialists working all over the United States.
Some CDI teams were built around the belief that registered nurses, both with and without CDI and coding credentials such as the CCS or CDIP, are the best fit for the job. Other CDI teams were assembled based on an assumption that health information management (HIM) professionals with some combination of coding or CDI credentials best fit the bill. But there’s a third option that some providers—and AHIMA—believe works best: the hybrid approach. Ideally, a hybrid CDI team consists of both credentialed HIM professionals and registered nurses.
In practice, a hybrid team builds on the strengths of both HIM and nurse professionals’ skillsets. A hybrid team benefits from the knowledge of coding guidelines and compliance expertise through its HIM professionals, as well as the intrinsic clinical relationships that have been forged between nurses and physicians. Facilities with functioning hybrid teams have already started to see clear financial benefits of working this way, according to several CDI experts interviewed for this article. They also see it as an opportunity to put to rest some of the tensions that exist between nurses and HIM professionals.
As the prominence of CDI has grown in response to reimbursement reforms and expansion into outpatient settings, some HIM professionals remain frustrated by what they see as resistance created by the notion that CDI requires clinical experience that only nurses can bring. Some feel as if they are being pushed out of CDI based on the myth that HIM professionals are insufficiently clinical. To understand why hybrid CDI teams hold the most promise for providers, it’s important to understand the history of CDI and why tensions exist between HIM and nursing professionals in the first place. To overcome this rivalry, both sides need to acknowledge how their backgrounds and skills complement each other, and why cooperation between them can result in the best documentation possible.
CDI’s Past and Present
Over the last 10 years, with the advent of electronic health records (EHRs), clinical documentation has largely become electronic—leading to numerous changes in the way nurses, physicians, and HIM professionals do their jobs. Historically, CDI has been a function of HIM and medical record departments. Approximately 25 years ago, hospitals started practicing “concurrent coding”— CDI’s precursor. Concurrent coding was performed by coding professionals who worked on hospital floors coding charts of patients who were currently in the hospital and querying physicians for additional details. The need for CDI grew when diagnosis related groups (DRGs) came on the scene, but CDI still wasn’t a priority for many providers.
In recent years, however, with the implementation of payment reforms tying reimbursement to quality-based care, CDI’s profile began to rise. This time around, consulting companies and CDI software vendors gained a foothold with providers and started urging hospitals to move nurses working in areas like quality and utilization review—which were also HIM domains—into CDI.
“The purpose of our profession [HIM] is to ensure that quality documentation supports the needs of healthcare and we’ve been doing that all along,” says Pamela Hess, MA, RHIA, CDIP, CCS, CPC, lead faculty, healthcare informatics at Grand Canyon University, and vice president, strategy and operations at MedASTUTE Consulting.
In an effort to better understand HIM’s current reach in CDI and to see how nurses and coders stack up in CDI roles, AHIMA recently conducted a survey that was sent to individuals in AHIMA’s member database who identified themselves as CDI or coding professionals, and to those who had one or more of the following credentials: CDIP, CCDS, CCS, RN, BSN, MSN, FNP, or MD. According to the survey, roughly 59 percent of respondents said their facilities hire HIM professionals for CDI roles, while 41 percent do not. As for which department oversees CDI, 51 percent of respondents said their CDI teams report to the HIM department, and roughly 18 percent of CDI reports to the finance department. The survey also found that the most frequently required credentials for CDI specialists were the RN and CCS, while the most frequently preferred credentials were the CDIP and CCDS.
When respondents were asked why they chose not to hire HIM professionals and coders for CDI, they responded that they were looking for staff with clinical knowledge—a curious response given that clinical documentation has long been considered the defining territory of HIM.
“Nurses and physicians have experience in applying clinical knowledge in direct patient care and HIM/coding professionals have experience in applying clinical knowledge in the accurate representation of diagnosis and procedural codes,” the survey report states. “Both of these areas of clinical knowledge are crucial in the accurate representation of patients through clinical documentation.”1
Nobody disputes that nurses and HIM professionals are qualified for CDI roles, based on both their professional experiences and educations. HIM professionals with RHIA and RHIT credentials and registered nurses undergo similar—if not identical—coursework, including classes in medical terminology, anatomy, physiology, pharmacology, pathophysiology, biology, chemistry, and clinical pathology, according to Paul Evans, RHIA, CCS, CCS-P, CCDS, clinical documentation team staff member at Sutter Health, who currently works on a CDI team made up of HIM professionals and nurses.
As someone who has worked on CDI teams with registered nurses and even physicians, Evans sees nurses and HIM professionals as equally qualified—but pushes back against what he sees as a pervasive assumption that HIM professionals don’t have the clinical chops for CDI.
“When I was trained, one of my last courses in college was from a physician. He’d give us signs and symptoms and we had to stand up and say, ‘I think the patient has pneumonia and diabetes, here are the tests I would order.’ He was training us to think critically and clinically so that we could have a conversation with a physician,” Evans says.
He notes that when working with nurses, some have been surprised by the depth of knowledge coding professionals bring to CDI.
“There’s a different mindset when you’re looking at evidence and thinking critically about that rather than simply following the orders. The RNs were surprised we think that way. But really, it’s just germane to how I was trained,” Evans says.
One reason that nurses, vendors, and consultants might underestimate coders’ clinical expertise and what they bring to the table is the fact that coders are out of sight. Many more providers are outsourcing coders and letting them work remotely. Physicians still receive queries from coders, but that’s the extent of most interactions.
Debra Beisel Denton, RHIA, CCS, CCDS, CDIP, CRCR, CICA, supervisor, HIM system coding educator, revenue cycle and inpatient coding auditor at Maricopa Integrated Health System, agrees that remote coders aren’t as able to demonstrate their clinical knowledge to colleagues. She says technology that allows remote work such as EHRs and coding platforms are great, but they eliminate occasions for HIM professionals to talk shop.
“I see it as a disadvantage to not have a peer next to you to talk to and discuss cases—so they’re missing out on that,” Denton says.
Nurses do have that ability to have clinical discussions with doctors, which helped them edge into HIM’s CDI territory.
“They bring a unique perspective with their clinical experience—and the fact that they have built and understand how to drive relationships with providers,” says Deirdre LeBlanc, RHIA, vice president for HIM, Parkland Health and Hospital System, in Dallas, TX, where CDI specialists are RNs and report to her in the HIM department.
LeBlanc says CDI specialists at Parkland are all nurses currently because when CDI staff transitioned from the case management department to HIM, the department was staffed by nurses. However, it is her interest and intention to hire both coders and nurses depending on their availability and skill. In addition, if CDI specialists don’t come in with a credential, they would be required to earn one during their time at Parkland.
While it can be accurate to say that some physicians have a higher level of comfort working alongside nurses and communicating with them, the mindset that this domain belongs to clinicians alone is one that that HIM professionals can—and should—resist.
In CDI, “the HIM professional brings an in-depth understanding of coding guidelines and an understanding of the content that’s required in the clinical record to support so many things,” Hess says. “Not only an accurate code, but medical necessity guidelines and an understanding of how a payer reads the record and accepts it and pays the claim.”
Hess notes that it’s not easy for someone who has never studied coding or coded themselves to understand how far-reaching coding is. HIM professionals with coding backgrounds understand how researchers and organizations such as the Centers for Disease Control and Prevention use codes to identify patient populations and conduct statistical analyses to reach conclusions on treatments and diagnoses.
“We have an advantage there in that we know that process and how the clinical record connects to a code number. HIM professionals know more about how to analyze data, where to find it, and how to present it. We also have a lot of experience managing processes and workflows and leading large groups of people. HIM departments are often led by individuals who used to be coders,” Hess says.
The Case for a Hybrid Dream Team
It would take work to transition CDI teams made up of only nurses or only coding or HIM professionals to a hybrid team with a perfect ratio of each perspective. But providers that have been lucky enough to deliberately hire a mix are glad they did.
In her consulting work, Hess encourages providers launching CDI programs to hire a team that’s made up of half clinicians and half individuals with HIM backgrounds. When facilities have the option of including physicians in that group, all the better. In many places, CDI teams comprised of foreign-born MDs have also been successful.
Hess says that if she were to assemble a hybrid CDI “dream team” she would have nurses paired up with HIM professionals and they would be given the same tasks during the workday. Ideally, the pairs would set aside 10- or 15-minute meetings at the beginning and end of each day to discuss their cases.
“That’s a really nice learning tool and it also helps build their relationship together,” Hess says. “In complicated care settings there are always issues that need to be talked through.”
Irina Zusman, RHIA, CCS, CCDS, director of HIM, coding, and CDI initiatives at New York University Langone Health, was encouraged to form a hybrid CDI team by a consultant who had seen good results in other facilities. Zusman says the suggestion was quite a new concept at the time. Once she had a blended CDI team in place, however, they became “famous” at the facility for helping physicians with documentation questions, in part because the HIM professionals on the team understood data analysis and clinical concepts.
“It came to the point where we don’t have to run after the physicians. They’re coming to us because they know we can help and analyze data and explain how they can improve their reimbursement using some other methods. How they document so they can directly capture PSIs, what kind of clarifications they can provide. So yeah, I think that we were lucky in many respects,” Zusman says. “I talk to people who say, ‘We only hire RNs with ICU experience’ or ‘We don’t hire foreign medical graduates,’ and we have foreign medical graduates working in our program. I think that CDI is a multifaceted profession, and every background brings something else and enriches it. We are living in the era of data. In order to analyze data you really have to understand coding.”
Having hybrid teams lets CDI professionals play to their strengths while acknowledging areas where they might have knowledge gaps.
Carolyn Page, CDIP, CCS, coding manager and CDI liaison at Sisters of Charity Leavenworth Health System, oversees clinical documentation specialists who are all nurses that are required to get a CDI credential. Even though her clinical documentation specialists aren’t hybrid by definition, they work in close collaboration with coders. The team has taken an integrated approach to pre-bill reconciliation where clinical documentation specialists and coders work together on every bill.
“With implementation of the CDI program, it was a great opportunity to collaborate and bring the clinical and coding side together,” Page says. “The reason we like it is that you just give everybody the opportunity to do what they do best. Nurses do clinical, coders do coding, then we bring them together before the bill goes out the door and hopefully get a bill that comes back without a denial—and the cooperation has paid off.
“We decreased our rebill percentages dramatically because of pre-bill reconciliation… The other thing was satisfaction among the team. Coders learned so much from CDS [clinical documentation specialists] and CDS learned from coders at the time of coding, even if it was email back and forth. We’ve seen tremendous increases in job satisfaction,” Page says.
One thing on which healthcare professionals on both sides of the CDI qualification spectrum agree, however, is the notion that CDI shouldn’t be considered solely the domain of professionals with one background. CDI professionals should be hired, they say, based on their abilities, skills, training, and competence.
“Part of the conversation around the CDI role is one of the things I find people don’t talk about,” says Sutter Health’s Evans. “I’m being very honest. I have a lot of RN friends that are wonderful in this role. I’ve trained many RNs. I’m not saying only we [HIM] can do this. I’m saying if a person displays the critical skills and abilities to think critically and logically and work in a compliant manner with clinical knowledge, the person should be considered suitable for this role.”
- Combs, Tammy. “The State of CDI.” Journal of AHIMA 90, no. 4 (April 2019): 18-21. http://bok.ahima.org/doc?oid=302702.
Mary Butler (firstname.lastname@example.org) is associate editor at the Journal of AHIMA.
Butler, Mary. “Coders or Nurses for CDI Teams: Why Hiring Both to Collaborate Works Best.” Journal of AHIMA 90, no. 7 (Jul-Aug 2019): 10-13.