Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor

Published Originally by AAPC Healthcare Business Monthly: https://www.aapc.com/

The need for clinical documentation improvement specialists is on the rise.

You’ve probably seen the acronym CDI (clinical documentation improvement), but do you understand the CDI specialist’s role in an organization’s daily workflow with regard to educating and training physicians, non-physician practitioners (NPPs), and other
clinical staff?

CDI specialists are an integral part of ensuring that provider documentation and the medical record are complete, accurate, compliant, reflect the patient’s severity of illness, and support billed diagnosis codes. CDI bridges the gap between coders and practitioners. This is why we’ve seen an increase in both onsite and remote job postings and programs created for CDI specialists in recent years.

Roles of a CDI Specialist

CDI specialists often work in the inpatient setting, reviewing patients’ charts for diagnosis coding. Most importantly, they ensure documentation supports patient care and management of diseases and chronic conditions. CDI specialists may also work in the outpatient setting on compliance auditing team, analyzing data algorithms and reviewing documentation guidelines, medical necessity, and diagnosis specificity, all of which may affect risk adjustment, claim denials, and provider reimbursement. The CDI specialist will often work with a “CDI physician champion,” a provider who recognizes and supports the mission of CDI and its initiative to improve documentation. The physician champion serves as a bridge between CDI and other physicians/colleagues.

Daily duties of a CDI specialist may vary depending on the organization and department they work in, but a day as a CDI specialist may include the following:

• Ensures the accuracy and completeness of clinical information for measuring and reporting physicians’ and
  hospitals’ documentation and medical records
• Conducts concurrent reviews to ensure there is proper documentation as required for Medicare, Medicaid, and
  commercial payers
• Analyzes statistical and clinical data of patients, treatment plans, and discharge summaries
• Tracks outcomes for individual patients to measure the quality of services provided
• Tracks responses and queries into the organization’s database/tracking tool and follows up with doctors and
  nurses where needed to complete a patient’s records
• Collaborates with coding staff and CDI physician champions to ensure patient records reflect clinical status
  and care provided
• Educates medical and coding staff on clinical documentation opportunities, coding and reimbursement issues, and
  performance improvement methodologies
• Demonstrates an understanding of complications, comorbidities, case mix, and the impact of procedures on the
  billed record
• Participates in CDI initiatives and provides opportunities for documentation improvement for systems

CDI Education and Job Requirements

If you search job listings on websites, a CDI specialist will require a clinical background and may look for nurses, NPPs, and advanced practice providers (APPs) like nurse practitioners, physician assistants, and even physicians. If you’re interested in transitioning to a role as a CDI specialist, speak to someone already in the role who can provide advice, and research various postings to understand the educational requirements and job descriptions. Some CDI roles may require you to have the following:

• A clinical background, with a minimum of an associate or bachelor’s degree in nursing and a master’s degree in health informatics
• Current state license to practice in the state in which you will work, unless it’s a remote job, which only requires an active license
• A minimum of 2 to 5 years of experience in a CDI role
• Proficiency in a medical record review
• Excellent presentation skills
• Soft skills, including excellent interpersonal and written skills
• Excellent analytical skills
• Strong computer skills, with knowledge of Microsoft 365 (Excel, Word, PowerPoint)

Strong computer skills have moved up the ladder of requirements lately as hybrid and remote work has increased significantly since the COVID-19 pandemic. Employers want to ensure candidates have what it takes to work independently and communicate virtually.

Some outpatient CDI programs may not require a nursing degree but may require that applicants have completed or hold a certification from an accredited program such as AAPC’s Certified Documentation Expert Outpatient (CDEO®), Certified Documentation Expert Inpatient (CDEITM), or Certified Risk Adjustment Coder (CRC®). These courses cover medical terminology, anatomy and physiology, pharmacology, documentation requirements, chronic conditions, disease processes, coding guidelines, management of patients’ conditions, and how to educate a provider efficiently after review.

What Is on the Horizon for CDI?

As healthcare moves toward value-based payments, organizations will continue to see the importance of implementing CDI roles and programs to support the increasing demand for accurate and compliant clinical documentation in inpatient and outpatient settings. Remember, a CDI specialist’s role is not to work against providers and other clinical and coding staff but to work with them to ensure a decrease in population risk, an increase in data quality for patient care, quality reporting of documentation, and an increase in revenue.

Resource

CMS Pub 100-04 Transmittal 11288

www.aapc.com