By Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA
The clinical documentation improvement (CDI) profession is flourishing as more organizations see the wide range of benefits a robust CDI program has to offer. The benefits of a CDI program include complete and accurate clinical documentation that supports correct reimbursement, proper reporting of physician and facility quality scores, and increased collaboration and communication between providers, CDI professionals, and coding professionals.
What It Takes to Become a CDI Professional
CDI professionals come from a variety of backgrounds, including health information management (HIM) coding professionals, physicians, nurses, and other professionals with a clinical or administrative background. Depending on the structure of the CDI program, the staff might consist of HIM coding professionals only, nurses only, or a combination of both. Some programs have a dedicated physician advisor who conducts reviews and communicates with other providers on documentation issues.
More important than the background of the CDI professional is the skill set he or she brings with them to the job. CDI professionals must possess knowledge and skills on the following:
- Disease processes, including clinical indicators
- Revenue cycle, including payment systems and methodologies
- Coding concepts and guidelines for ICD-10-CM, ICD-10-PCS, and CPT (if doing outpatient CDI)
- Healthcare regulatory compliance
- Health record documentation requirements
- Quality reporting requirements
- Software tools (i.e., encoder, querying tool, reporting)
- Strong written and verbal communication
- Critical thinking
A review of CDI job descriptions conducted by the AHIMA Foundation in 2014 revealed that the average amount of experience necessary was four years, and most job descriptions required a baccalaureate degree.1 The study also showed that the majority of CDI job descriptions surveyed indicated nursing as the required or preferred certification/license. However, keep in mind that this study was conducted in 2014. A review of today’s job descriptions may very well tell a different story with the implementation of ICD-10-CM/PCS showcasing the need for individuals with advanced skills in coding concepts and guidelines being necessary in CDI.
How Does Coding Fit Into CDI?
Coding professionals have most, if not all, of the requisite skills to become CDI professionals. They have advanced level knowledge of coding guidelines and concepts, understand the revenue cycle process and compliance issues, and know health record documentation requirements. They are aware of quality issues and the impact that accurate documentation has on them, use multiple software tools every day, and use critical thinking skills when reviewing records for coding. The two areas that some coding professionals may need to expand upon are clinical skills and the ability to talk one-on-one with providers.
When CDI professionals are doing concurrent reviews of records they are searching for clinical clues that might reveal a diagnosis that hasn’t been documented or might need more specificity. They review not just the physician documentation, but also nursing, ancillary (i.e., lab, radiology, physical therapy), and other reports to see the full picture of that patient. A thorough understanding of where to find pertinent information within the health record, as well as identifying gaps in the physician documentation, is paramount.
The advantage that a coding professional brings to the CDI process is that they understand the coding guidelines and know exactly how the documentation must read for the coding staff to code it accurately. For example, a coding professional would recognize that a documented diagnosis of “acute gastrointestinal bleed” for a patient who had a drop in hemoglobin and was transfused red blood cells would be assigned the ICD-10-CM code of K92.2, Gastrointestinal hemorrhage, unspecified. If the physician were to specify this as “acute blood loss anemia,” it would code to D62, Acute posthemorrhagic anemia in ICD-10-CM, which is likely a more accurate code based on the drop in hemoglobin and the treatment carried out. The coding professional has the skills to recognize the key words that a provider must use to get the most accurate codes assigned, based on years of practice assigning codes.
CDI professionals must possess the confidence and clinical skills to have one-on-one conversations with physicians. Most physicians are not up on the current coding guidelines and conventions, so it is the CDI professional’s role to educate them on the necessary documentation requirements in a way that they can understand. The physician does not want to be quoted a list of coding guidelines; instead, discussing the clinical indicators on the record and pointing out potential gaps in documentation that need to be clarified is a better approach.
Making the Move from Coding to CDI
A coding professional that wants to move into CDI needs to start with a self-assessment. Ask yourself the following questions:
- Do I have the clinical skills necessary to be successful in CDI?
- Do I feel comfortable discussing clinical issues with a physician?
- Do I know the coding guidelines and concepts thoroughly?
- Am I aware of the impact of inaccurate and incomplete documentation on the revenue cycle? Can I explain this to a physician who questions it?
- Have I kept up on all of the current quality initiatives in healthcare that are impacted by physician documentation?
- Do I know how to write a compliant query, without being leading?
- Do I have good written and verbal communication skills?
- Am I able to navigate through the entire health record to locate clinical indicators to formulate queries?
- Am I ready to take on a new challenge in my career?
If you answered “yes” to all of the above questions, you are ready for the move to CDI. If you answered “no” to any of the questions and you still want to pursue the CDI profession, then you need to take the necessary steps to gain those skills.
AHIMA Foundation. “Clinical Documentation Improvement Job Description Summative Report.” 2014. www.ahimafoundation.org/downloads/pdfs/CDI_SummativeReportFinal_.pdf.
Melanie Endicott (firstname.lastname@example.org) is a senior director of HIM practice excellence, CDI/EHR, at AHIMA.
"Transitioning from Coding to CDI Offers New Career Opportunities"
Journal of AHIMA