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 Chinedum Mogbo MBBS, RHIA, CDIP, CCDS, CCS
Clinical documentation improvement (CDI) is the recognized process of improving healthcare records to improve patient outcomes documentation, data quality, and accurate reimbursement. The profession has grown in response to the Centers for Medicare and Medicaid Services (CMS) Diagnostic-Related Group (DRG) system, and gained greater notice around 2007. CDI professionals act as intermediaries between coding professionals (who translate diagnoses into data), healthcare providers, and nurses. As many clinical coding professionals don’t have patient care backgrounds, and healthcare providers may not realize the importance of accurate documentation, CDI professionals serve as the connection between these two groups.1
CDI has become a hot topic over the years, with widespread interest and debate regarding who qualifies to be a CDI professional. The fact that there is little specialized academic education or curriculum for CDI only intensifies the debate.
Generally, because of their medical background and experience interacting with physicians, registered nurses (RNs) have been looked to when it comes to filling CDI roles. A strong medical background is essential to critically analyze a physician’s documentation and tie together the clinical picture that the documentation is intended to reflect.
While nurses have dominated the CDI field for a while, we now have other medical professionals like physicians (both US- and foreign-trained), physician assistants, medical school graduates, and coding professionals who have started to make a mark in the CDI world.
As previously noted, a strong clinical background is beneficial to accurately review a health record, but coding knowledge is also a valuable skill set to precisely interpret the health record data. The role of CDI is a good fit for a variety of healthcare professionals—including coding professionals, who through their experience in reviewing health records understand the complexities of documentation.
Although we still have some healthcare organizations restricting the hire of CDI professionals to only RNs (I still see job advertisements requesting that only RNs apply), a good number of healthcare organizations have come to the realization that medical graduates, physicians, physician assistants, and coding professionals can also be a good fit for CDI roles—which is truly encouraging. I believe everyone with medical background andknowledge, good communication skills, good critical and analytical skills, and coding knowledge make excellent CDI professionals.
I am a foreign-trained physician who has worked in the CDI world for a good number of years, and I can say that the CDI world, with time, has opened up to be more accepting of other professionals. I have trained a good number of foreign-trained physicians in CDI and I have seen them flourish as CDI professionals.
My only hope is that organizations like AHIMA and ACDIS blaze the trail and encourage organizations to think outside the box when hiring CDI professionals.
- Brown, Linda Renee. (February 2013). “The secret life of a clinical documentation improvement specialist.” Nursing 43 (2) (Supplement): 10–12. http://www.nursingcenter.com/journalarticle?Article_ID=1493953&Journal_ID=54016&Issue_ID=1493946.
Chinedum Mogbo is manager, CDI for Tenet Health’s California Market.