Skewed Public Perception of the CDI Role and Impact in Healthcare

This monthly column will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.


By Autumn Reiter, BSN, RN, CCDS, CDIP, CCS, AHIMA Certified ICD-10 Trainer

 

When I explain my role as a clinical documentation specialist to people, the first question that comes up most frequently is the financial impact of my job. With the plethora of information given to the public via medicine-related dramas and news broadcasts, it is no wonder they ask this question. While the healthcare industry in the United States is complex—as health information management professionals are well aware—the end goal of clinical documentation improvement (CDI) is to promote the accurate “story” of each patient’s stay. When people get this answer, their response is often a perplexed look accompanied by the question, “But you are trying to get more money, right?”

It seems lately that every time you turn on the television there is a new medical drama starting. Unfortunately, the depiction of healthcare and the patient encounter is offered in a very skewed view depending on the storyline and intended impact. Some have gone as far as to note that any financial impact should be over looked and that it is a discredit to the profession to be cognizant of the financial burdens and rising healthcare costs. Although cost of care should not drive healthcare providers’ treatment decisions, accurate documentation is essential to obtain payment for the services rendered and assign the proper codes associated with those services.

But our jobs do not end there. We help ensure accurate data is collected for reporting, that the information the public is receiving via the public reports is correct, and that they are informed about facilities care and services. We review quality components and safety measures, all of which helps healthcare consumers make informed decisions on where to receive healthcare and who will provide that treatment.

The following analogy is a useful illustration to help those new to the CDI profession understand the impact of CDI. Let’s say you were seen at your local hospital, but six months later you take a trip to Europe and become ill. The providers there request your records from the states to help treat you accurately. Although there is potential a spoken language barrier, if the ICD-10 codes are as accurate as possible, there should be no concern. These function as a language of their own and it is the responsibility of CDI to make sure those codes fully depict the diagnoses noted. When we discuss any item, being as descriptive as possible creates a picture of what we are discussing. I can tell you I have a bike, but if I describe that bike as being a blue and white road bike, then the picture is much more clear. In turn, a provider’s note can say the patient had pneumonia, but if we can capture aspiration pneumonia due to swallowing difficulty following CVA, the picture again is very different and paints a clearer picture. CDI professionals are the translators for the language of ICD-10. They serve as the editors to each patient’s healthcare novel, each chapter closely reviewed for increased specificity that will allow for a more accurate story to be told through their reviews, queries, and conversations with providers.

Even though CDI professionals are not providing care at the bedside, they are still helping patients—just in a different way. It is essential for all CDI professionals to make sure each record is as accurate as possible, and that the providers understand the importance of the details in their documentation and the impact that has on their patients’ care—as well as the impact these details can have for the organization. Hospitals are businesses, and, yes, there is also a financial impact aspect to the importance of CDI as well—but that is only a small piece in a much larger story.

 

Autumn Reiter (autumn.reiter@TrustHCS.com) is director, CDI services at TrustHCS.

6 Comments

  1. The coders are the ones who put the accurate codes in and do the most work for the hospital. CDI are not coders, not do they have the experience. The coders deserve the recognition for hard work and financial end of the hospital!

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    • I’m a coder, have been for over 10 years. I just started as a CDIS in the last year. If they have Coders as opposed to RNs doing the job, er capture that much more.
      Theres more to it than you know.

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  2. A mentor of mine once told me: “You can expect what you inspect”. Over the years I have found this axiom to be true.

    No funds should be freely given to any enterprise, without tying it to auditing and process improvement. Especially, enterprises where individual health and lives are at risk.

    I liked your reference to the often skewed view presented in the medical drama storylines. I have often suggested that AHIMA consider contracting with a Hollywood product placement agent. Not to place our products, but instead place our mission and vision.

    Consumers should hear more than a skewed negative view. There is plenty of human drama in what we do everyday to improve outcomes, that would make for exciting storylines.

    Post a Reply
    • Coders code based on the documentation; CDI’s make sure the documentation is accurate. Both work together.

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  3. I completely agree that the perception of CDI is skewed, but not just by the public, but by pretty much everyone. Most people both inside and outside of healthcare have no idea what CDI is. Those who have heard of CDI think that our job is specifically to increase reimbursement because that seems to be how we justify our roles in the organization. I just recently started working in CDI after having been a Coder for several years, and when I try to explain to people what a CDI specialist does they either tune me out as not being important, they don’t understand why someone like me is needed in the first place (because isn’t CDI basically done by Coders, so why do we need another person doing that?), or they begin the complaint about how healthcare is so expensive because of all the non-revenue generating jobs and how overly complex is the healthcare system. I’ve heard from a few CDI that they felt much more appreciated in their previous professions as nurses or coders.

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  4. It is my recent experience that CDI reviewers are woefully ignorant of Official Coding Guidelines and Coding Clinic Advice. CDI should be focused on “documentation improvement”, not coding accuracy. CDI reviewers are not qualified to judge coding accuracy.

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