by Rebecca Hendren, Association of Clinical Documentation Improvement Specialists
There is a lot of discussion about how to be a good clinical documentation improvement (CDI) specialist. As the profession grows and facilities need to hire new CDI team members, many more people are looking to get into the field. CDI specialists can come from any background in the medical field. Although many CDI specialists are clinicians, coders are increasingly interested in pursuing opportunities to apply their skills as CDI professionals.
To perform CDI responsibilities, clinicians must become proficient in a number of adjacent knowledge domains that HIM professionals know well: medical record review, medical coding and reimbursement regulations, the impact of reportable diagnoses on quality of care measures, risk adjustment methodology, and both the Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS).
While those from coding and HIM backgrounds may not have the same clinical expertise as nurses or physicians, they do have extensive knowledge regarding coding rules and requirements—they know the regulatory side of the equation. In order to perform CDI responsibilities, coders and HIM professionals must expand their skills in those areas clinicians know well: the ability to understand the clinical picture of the patient and identifying areas of missing documentation or those that need clarification.
Since hospital coders already have experience working with clinicians, revenue cycle staff, and others throughout the hospital, they can quickly find their place in the CDI team. Their knowledge of documentation, who is involved in the diagnostic process, and how procedures are completed make them well suited to the CDI role.
Many employers recognize that CDI professionals with coding backgrounds can provide a complementary perspective to those coming from clinical roles. Working well with others and collaborating are key. Communication skills (both written and verbal), imagination and creativity, and analytical and problem solving skills are also a must.
ACDIS CDI Apprenticeship
A Coder’s Pathway to CDI! Finish the ACDIS CDI Apprenticeship and become an ACDIS-Approved CDI Apprentice. Learn more here.