This Practice Brief has been updated. See the latest version here. This version is made available for historical purposes only.
The role of the clinical documentation improvement (CDI) professional is ever-changing. When CDI programs first began in the late 1990s, the focus was almost exclusively on acute care Medicare patients. Today, as external influences such as fraud and abuse programs, changes in reimbursement, complexity of care, and quality report cards increase the need to tell an accurate patient story across the continuum of care, CDI programs are morphing at a rapid pace. Their goal is to accurately tell the patient’s story.
As the healthcare industry continues to expand and become more dependent on clinical information for real time outcomes reporting, there is a need for an increased number of CDI professionals. The Commission on Certification for Health Informatics and Information Management (CCHIIM) explored this CDI role in 2011. Through a job analysis methodology that included a random sample of 4,923 CDI-related professionals, a thorough foundation for the clinical documentation improvement practitioner (CDIP) credential was established.
This Practice Brief will outline the benefits of the CDIP credential so that organizations and providers can be assured that their CDIP-credentialed staff are ensuring clinical information supports clinical care, treatment, coding guidelines, and reimbursement methodologies.
Skills and Background
Emerging professions or job roles bring an exciting air of possibility. New specializations continue to emerge because of a variety of regulatory and environmental factors. For CDI, the need for specialization emerged to certify individuals working in clinical documentation roles to ensure the integrity and quality of their work. In an effort to fill an industry need for a validated professional standard of CDI excellence, CCHIIM used job analysis data to develop the CDIP credential exam blueprint in accordance with test development best practice methodology.
As a result, six domains were developed to create knowledge-based content areas of expertise:
- Clinical coding practice
- Record review and document clarification
- CDI metrics and statistics
- Research and education
These six domains are weighted based on subject matter experts’ rankings of task or knowledge criticality and frequency. The exam is based on validated, job-specific content so that those who achieve the CDIP credential have proven their competencies and expertise related to the codified CDI body of knowledge. As a result, the healthcare industry is strengthened by this defined, measurable proficiency related to the quality of clinical documentation.
Importance of Credentials
The delivery of healthcare continues to change, creating a need for changes in industry personnel. However, one thing that will never change is the need for qualified leaders. Leadership will always involve communication, education, and collaboration—all key skills for the CDI professional. Regardless of an individual’s healthcare background, the acquisition of the CDIP credential signifies that he or she is a professional with key leadership skills. The CDIP credential identifies individuals who place importance on acquiring and maintaining knowledge and skills. Hiring managers will look for this credential as a sign of competence and professionalism. The credential also demonstrates to other disciplines a certain level of clinical competence required for documentation review.
Organizations and providers are fully aware of the need for accurate and timely documentation. Employing a CDIP professional ensures that there is a qualified individual with a thorough understanding of the latest documentation, code assignment, metrics, and compliance information. In addition, credentialed professionals may be elevated to management positions at a faster rate than their non-credentialed counterparts.
As with any industry, the healthcare industry recognizes advanced skills. CDIP professionals are often in a position to negotiate a higher rate of pay because the credential indicates a higher level of knowledge and a commitment to training and continuing education. In an industry where associate and baccalaureate degrees are almost undeniably required, and many management positions require a master’s degree, a credential can make a difference in salary range.
AHIMA requires CDIP professionals to follow high standards of professional and ethical behavior. These standards are outlined in the AHIMA Code of Ethics and Ethical Standards for Clinical Documentation Improvement Professionals, and require continuing education hours to maintain the credential. These higher standards associated with the CDIP credential can automatically boost professional reputation within the organization and healthcare field.
CDI and HIM Naturally Overlap
Health information management (HIM) professionals have the core fundamental skills associated with documentation, coding, compliance, and information management that lend themselves to documentation improvement. According to a report from the AHIMA Foundation, 79 percent of work on clinical documentation improvement is conducted in the HIM department. As industry initiatives push forward with programs such as ICD-10-CM/PCS implementation, accountable care organizations reimbursement models, fraud and abuse compliance programs, and implementation of electronic health records (EHRs), the importance of these fundamental skills cannot be overstated. CDI professionals can also assist case managers with meeting the Two-Midnight Physician Certification requirements.
Organizations implementing CDI programs depend on HIM professionals’ skill set. The convergence of clinical, documentation, and coding processes is vital to a healthy revenue cycle—and, more importantly, to a healthy patient.
HIM professionals also impact CDI programs by providing education on compliant documentation practices to all clinicians. Organizations must compensate for this lack of training by instituting CDI programs that align with good documentation habits. HIM professionals, through their education, are familiar with compliant documentation rules and regulations as well as accreditation standards that affect timely documentation. In addition, HIM professionals are also familiar with important areas such as privacy, security, and confidentiality that also impact the sharing of clinical information.
As technology changes the way documentation is captured through the use of EHRs, the need to have highly trained and qualified professionals in CDI roles becomes more evident. The CDIP credential distinguishes the HIM professional as a subject matter expert on documentation and demonstrates competency in capturing documentation necessary to fully communicate a patient’s health status and condition.
CDI Important to ICD-10 Success
An AHIMA-credentialed CDI professional possesses the skill and knowledge necessary to work collaboratively with patient care providers to obtain the increased specificity needed in the ICD-10-CM/PCS code sets. The CDI specialist educates the provider at the point of care to ensure the patient record contains the most specific, accurate, and compliant documentation that adequately reflects quality of patient care while increasing accuracy in coding and reporting.
Specificity of code assignment in ICD-10-CM/PCS impacts various areas, including medical necessity, risk of mortality, severity of illness, value-based purchasing, denials and appeals, quality core measure indicators, hospital and physician profiling, and reimbursement. Studies have shown that some hospitals currently lacking a CDI program have experienced up to 25 percent of denied claims due to unspecified diagnoses in preliminary ICD-10 gap analyses.
CDI Specialist Poll: What is Your Level of
Source: 2014 AHIMA CDI Summit Audience Poll
CDI Focuses on Quality Documentation
The focus of most CDI programs is on improving the quality of clinical documentation regardless of its impact on revenue. Arguably, the most vital role of a CDI program is facilitating an accurate representation of healthcare services through complete and accurate reporting of diagnoses and procedures.
A successful CDI program can have an impact on Centers for Medicare and Medicaid Services (CMS) quality measures, present on admission, pay-for-performance, value-based purchasing, data used for decision-making in healthcare reform, and other national reporting initiatives that require the specificity of clinical documentation.
American Hospital Association Coding Clinic authors accurately predicted in 1989 that data “will be used to judge both the quality and value of care provided by individual institutions and physicians.” Physician documentation and coded data now serve as the foundation for risk-adjustment methodologies, such as the CMS Hierarchical Condition Categories (HCC) and 3M APR-DRGs. Risk adjustment is integral to provider profiles used by the Agency for Healthcare Research and Quality (AHRQ), Premier, Healthgrades, US News and World Report rankings, and others.
Healthcare policymakers and payers use coded data to make important decisions. CMS outlined their intentions in the “Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program” by saying they were transforming the Medicare program from “a passive payer of services into an active purchaser of higher quality, affordable care.” Expanded programs are revamping how services are paid, moving increasingly toward rewarding better value, outcomes, and innovations. Commercial payers are also increasingly adopting strategies that focus on physician documentation and coded data to support quality initiatives, payment methodologies, payer contracts, and preferred provider arrangements.
Quality metrics, based in large part on coded data supplied through hospital claims, have proliferated in recent years and are widely disseminated across the Internet. Hospital Compare suggests such information “encourages hospitals to improve the quality of care they provide.” Consider that coded data is used by CMS for:
- Payment on an individual case basis
- Adjustment of individual payments because of hospital-acquired conditions
- Adjustment of base payments across a broad scale, such as Medicare base rates for an entire year due to special quality initiatives
- Value-based purchasing, with 50 percent to 65 percent of the facility performance score dependent on coded and risk-adjusted data for mortality rates, patient-safety indicators, and Medicare spending per beneficiary
- Readmission reduction program, based on select principal diagnosis codes and risk-adjusted cases for a growing number of diagnoses and procedures
- Hospital-acquired condition reduction program, where a portion of the score is based on patient safety indicators determined by coded data
- Case identification for inpatient quality measures, such as heart failure measures which are only applicable to patients with a coded principal diagnosis of heart failure
- Annual coding and documentation adjustment
Improving the accuracy of clinical documentation can reduce compliance risks, minimize a healthcare facility’s vulnerability during external audits, and provide insight into legal quality of care issues.
Ethical Standards and Credential Maintenance
Ethical standards are a core component of any profession. The AHIMA Ethical Standards for Clinical Documentation Improvement Professionals serve as a foundation for decision-making processes and actions. A key principle within these standards is to “Support the reporting of all healthcare data elements (i.e., diagnosis and procedure codes, present on admission indicator) required for external reporting purposes (i.e., reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.”
These standards also emphasize the need for maintenance of certification, including the CDIP credential, to continually enhance professional competency. Professionals holding a current CDIP credential have demonstrated commitment to staying abreast of an ever-changing healthcare field.
Healthcare organizations can be assured that their CDI professionals have demonstrated excellence in clinical care, treatment, coding guidelines, and reimbursement methodologies. In order to maintain certification through AHIMA, credentialed individuals are required to comply with the continuing education standards as set forth by CCHIIM.
It is recommended that healthcare organizations cover the expense of continuing education credits for their employees. Employer reimbursement for continuing educational opportunities allows the credentialed CDI professional to keep abreast of the latest developments; continues awareness of changing codes, practices, and regulations; and assures the employer, peers, and providers that the CDI professional maintains the highest level of competency in their respective healthcare field.
 Ryan, Jessica et al. “Validating Competence: A New Credential for Clinical Documentation Improvement Practitioners.” Perspectives in Health Information Management (Spring 2013): 1-38.
 Hall, Denise. “ICD-10 and Clinical Documentation Improvement Programs.” PYALeadership Briefing. June 2012.
 American Hospital Association. Coding Clinic (First Quarter 1989): 5-7.
 Centers for Medicare and Medicaid Services. “Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program.”
 Medicare Hospital Compare Website.
 AHIMA. “Ethical Standards for Clinical Documentation Improvement (CDI) Professionals.” 2010.
AHIMA. “Clinical Documentation Guidance for ICD-10-CM/PCS.” Journal of AHIMA 85, no. 7 (July 2014): 52-55.
AHIMA. “Clinical Documentation Improvement Toolkit.” January 2014.
AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no. 5 (May 2010).
AHIMA. “Recruitment, Selection, and Orientation for CDI Specialists.” Journal of AHIMA 84, no. 7 (July 2013): 58-62.
AHIMA. “Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS.” Journal of AHIMA 84, no. 6 (June 2013): 56-61.
Bresnick, Jennifer. “Top ICD-10 clinical documentation improvement pain points.” EHR Intelligence. January 6, 2014.
Commission on Certification for Health Informatics and Information Management. “AHIMA Candidate Guide.” May 2014. www.ahima.org/~/media/AHIMA/Files/Certification/Candidate_Guide.ashx.
Hart-Hester, Susan. “Clinical Documentation Improvement (CDI) Job Description Summative Report.” Prepared for AHIMA Foundation. 2014.
Sheila Burgess, RN, RHIA, CDIP, CHTS-CP
Sharon Cooper, RN-BC, CDIP, CCS, CCDS, CHTS-CP
Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA
Susan Wallace, MEd, RHIA, CDIP, CCS, CCDS
Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, CPEHR, FAHIMA
Cecilia Backman, MBA, RHIA, CPHQ, FHIMSS
Patricia Buttner, RHIA, CDIP, CCS
Susan Clark, BS, RHIT, CHTS-PW, CHTS-IM
Marlisa Coloso, RHIA, CCS
Angie Comfort, RHIA, CDIP, CCS
Katherine Downing, MA, RHIA, CHPS, PMP
Pat Maccariella-Hafey, RHIA, CDIP, CCS, CCS-P, CIRCC
Laurine Johnson, MS, RHIA
Cathy Munn, MPH, RHIA, CPHQ
Cindy Parman, CPC, CPC-H, RCC
Angela Dinh Rose, MHA, RHIA, CHPS, FAHIMA
Donna Wilson, RHIA, CCS, CCDS, CPHM