This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Mary Ellen Devitt
As a student in health information technology (HIT), you hear many industry buzz words. All the various acronyms and mystical concepts remain a mystery until someone explains them, but it can be intimidating to step up and ask when you don’t know something. Since I am one of those students who was told there is never a dumb question, I am always willing to take the risk of looking a little foolish in order to ask what something means so everyone learns.
So when I heard the term “CDI” in one of my class lectures, I asked, “Ah… what does CDI stand for again?” Luckily, my professor is always willing to explain things if you are earnest in your desire to learn. She informed us that CDI is most often used as the abbreviation for clinical documentation improvement, but in some settings, the term may be used for clinical documentation integrity or clinical documentation initiatives. At this point, I thought, “Okay, CDI stands for clinical document improvement, but what does clinical documentation improvement mean?” Later that night, I started investigating what CDI meant on the internet, and looking through my textbooks for chapters/sections on CDI.
In my research, I realized I knew a lot more about clinical documentation improvement then I originally thought. I just didn’t know the industry term used for a professional who validates that each patient encounter includes accurate and complete clinical and diagnostic information. Furthermore, in my position working in patient financial services, I was probably the beneficiary of improved clinical documentation efforts. At the time, one of my primary functions was to search a patient’s electronic health record (EHR) looking for diagnostic and clinical reasons providers were ordering hospital outpatient tests and procedures related to the patient’s participation on a clinical research trial.
But then I thought, “What else do CDI professionals do?” At this point, I have learned that the below tasks are some of the key responsibilities for a CDI specialist. This list is based on sample language from a variety of job postings for clinical documentation professionals:
- Confirms that appropriate documentation supports diagnosis codes
- Checks the documentation for compliance and coding, and queries the physician if the documentation is incomplete
- Monitors and tracks verbal and written queries
- Identifies and reviews for present on admission diagnosis documentation
- Obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient
Furthermore, I also started looking at the different training programs and opportunities there were available to learn more about clinical documentation improvement (CDI) and found out that the American Health Information Management Association (AHIMA), of which I am member, has a number of webinars, resources, publications, and meetings on CDI—and even offers a training course to become a Certified Documentation Improvement Practitioner (CDIP). I also learned that there was a CDI Task Force being put together through AHIMA. Luckily, they were looking for volunteers and needed a student member. And since CDI is an area of HIT about which I wanted to learn more, I submitted an application to serve on this AHIMA Task Force and was selected.
So far in my role on the AMIHA CDI Task Force, I have probably learned more than I have contributed. But I hope that having a student’s perspective and a CDI novice on the team might be beneficial in a variety of ways. As a student and future HIT professional, one of the most relevant topics for me that the CDI Task Force has discussed, and will discuss more in the future, is the characteristics for a CDI professional and how one enters the field. One way to figure this out, I thought, would be to look at the skills and qualities employers were requiring or requesting in job postings for CDI professionals.
After doing a short review of job postings for CDI positions, including “CDI” in the title, it appears that most of these listings were only hiring registered nurses (RNs) or former nurses for CDI positions. Additionally, in my recent direct experience with two large hospital systems in the Chicagoland area, I asked personnel at each who serves in a CDI capacity at their institutions, and both systems at present only hire RNs to work as their CDI specialists. Within each of these hospital systems, CDI professionals reported to the Director of Nursing and not the Director of Health Information Management or Director of Medical Records, as I would have thought. I do see how CDI professionals who have been trained as nurses have a fantastic grasp of clinical terminology and treatment, especially if they had previously worked directly with physicians in providing care on a daily basis. So former nurses in the function of CDI professional does make a lot of sense, but the question is: are only nurses qualified to be CDI professionals?
As a member of the CDI Task Force, I have learned that AHIMA, as well as other professional societies such as the Association of CDI Specialists (ACDIS), are working to advance non-nurse trained professionals for CDI roles. They are looking at other education, professional experience, and training to expand the opportunities for non-nurse CDI professionals from other sources such as the ranks of health information management (HIM) professionals. This sounded promising to me, since I have coding training and will be seeking an RHIT certificate next summer, and am not trained as a nurse.
As further support for including HIM professionals in CDI functional roles, according to Chapter 6 of the Medicare Benefit Policy Manual, one way to determine how to best leverage CDI in an outpatient setting is through collaboration with other departments impacting the revenue cycle, including health information management or case management as “hospitals provide two distinct types of services to outpatients: services that are diagnostic in nature and other services that aid the physician in the treatment of the patient.”1
Through the Task Force discussions about what traits a CDI professional needs, it seemed to me some individuals felt that an individual does not have to be an RN to be successful as a CDI professional. As a non-nurse myself, I would agree that this profession may not necessarily be an exclusively nurses-only role. Many coding and HIM professionals often have the knowledge and experience with regulations and Medicare guidelines that are critical to a CDI role, even if it is not primarily clinical in nature. Some examples of other professionals that the Task Force identified who might serve in CDI roles included physicians, other clinical providers, foreign-trained clinicians, and RHIT/RHIA-certified and other HIM non-clinical professionals. The Task Force seemed to agree that professionals from these areas would have traits and experience that could make them successful in the CDI field.
- “Outpatient Clinical Documentation Improvement (CDI): An Introduction.” White Paper. May 2016. https://acdis.org/system/files/resources/outpatient-cdi-intro.pdf.
Mary-Ellen Devitt is a student in health information technology at Moraine Valley Community College.