A Typical Day for a CDI Specialist

by Deborah Bauer, RHIA, CCS-P

A Clinical Documentation Improvement Specialist, CDI can be employed as an Inpatient CDI and concurrently review documentation in the medical record, whereas an Outpatient CDI reviews the medical record retrospectively.

Purpose: Improve accuracy and the quality of Clinical Documentation

Benefits:

• Coding accuracy and precision
• Documentation of the severity of illness
• Justification for resources used in providing care
• Improved continuity of care
• Improved reimbursement
• Accurate case mix index
• Designates risk-adjusted
  

CDI goals:

• Enhance continuity of care for patients by improved, more precise, complete, and accurate documentation.
• Review and develop processes, polices, and provide education to staff in clinical areas to improve clinical documentation.
• The job duties are to review the medical record and send appropriate queries to the providers concurrently or retrospectively. Work closely with the physicians, residents, nurses, ancillary staff, and coders.
  

Skills:  

A CDI should be a team player with excellent verbal and written communication skills, interact with medical staff with a positive attitude, have problem solving and conflict management abilities.
 

Why become a CDI?

Reasons to be a CDI can be the following: CDI is a rewarding career field with salaries on the higher end and the job is in high demand. According to the OHIMA 2022 Salary and Benefits survey the average salary was $64,790 with a total of $66,442. If you are experienced as a coder or nurse who has experience in reviewing medical documentation, it can be a perfect transition to a new rewarding career. A CDI Specialist is also rewarding due to being directly involved in improving the documentation and reimbursement for the facility.

Consequences of no CDI program in the workplace:

What can be some of the consequences of not having a CDI program at your facility? A facility without a CDI program in place will have higher denial rates, decreased reimbursement rates, and increased readmission rates due to improper documentation and coding. This will also inadequately reflect the patient’s severity of illness, case mix index, quality scores, and health grades which are based on the coded data based on clinical documentation. 

Challenges of CDI Program:

• Scheduling time for formal physician education
• Getting providers to respond to the queries in a timely manner

For additional information on educational requirements and certifications please review the following websites: www.ahima.org or www.acdis.org. 

Certifications: Certified Clinical Documentation Professional, CDIP, Certified Clinical Documentation Specialist, CCDS

 

About the Author 

Deborah Bauer, RHIA, CCS-P, is currently employed as an Inpatient Clinical Documentation Specialist at the Dayton VAMC Hospital. Deborah has over thirty years’ experience in the HIM field. She has experience in federal hospitals, private sector, mental health facilities, nursing homes, and outpatient pediatrics. She has been employed as an Inpatient and Outpatient Coder, Medical Record Supervisor, Release of Information, Teacher, Transcriptionist, and Medical Biller.

Deborah was previously employed at Miami Valley Hospital as an Inpatient Coder. She obtained a bachelor’s degree at the University of Cincinnati in Health Information Management and an Associate degree in Medical Records at Sinclair Community College. She obtained her RHIA, and CCS-P certifications. She has volunteered with OHIMA in Professional Coding and CDI projects, and is presently on the OHIMA Blog Committee.

My Journey to Becoming a Cancer Tumor Registrar

by Cheryl Radin-Norman, LPN, RHIT, CTR

Outsourced overseas, now what? That was how I felt when the boss called a meeting and told us that we were being replaced. All my plans disappeared with that one word. I was an ED/Observation Coder and happy at my job. But seeing it outsourced was a kick to the gut. So now I know I needed something that would be harder to outsource. Then I remembered working alongside another HIM Professional at the hospital and she was a Cancer Tumor Registrar or CTR. We used to lunch together, and I learned that she had a very interesting job that included coding and research, just what I loved to do in the coding field. Not only that, but she traveled and educated others about what her job meant to the cancer field. She also worked alongside doctors in Cancer Committee and Tumor Board Meetings. Cancer Tumor Registrar seemed to be as challenging and life changing as coding work. This field offered diversity and growth, and the market was wide open. Plus, how could this be outsourced? So, how to become a CTR.

After researching, I discovered that there were a couple of programs available to sit for the CTR Certification. I enrolled in University of Cincinnati (Go Bearcats!) and discovered that I was learning to love this program as much as I loved coding. I also discovered that this area of HIM is not as well known as many of the other areas. So now that I have my CTR and am working in a State Central Registry, my goal is to introduce as many people as possible to this area of HIM and hopefully entice others to make the leap to this rewarding career.

What does a CTR do? You can work in the State Central Registry where data is collected from all the facilities that diagnose and treat cancer. After collecting the data, it is consolidated before being sent to the national databank (CDC) to be used for clinical trials and clinical research for cancer treatments. Or you can work in the facilities gathering the data from the patient’s charts and creating abstracts telling the story of the patient’s cancer, from diagnosis to treatment to remission or cure, following them for the rest of their natural lives. There is also the opportunity to attend Cancer Committee meetings and the Tumor Board Meetings. All integral areas for collecting data so that the research can continue and improve the lives of those cancer patients. It is a fast paced and constantly changing field where you can feel that you are making a difference in the lives of those with cancer. 

Now that I am a year passed certification and working in the field, I find I am constantly learning, and it has become a most rewarding experience. I get up excited to go to work and enjoy my job because I can truly feel that I make a difference. Years ago, when I used to teach in the HIM field, I told my students that they were choosing the best healthcare field to enter because the opportunities were endless. And I have proved it in my own career.
 

About the Author  

Cheryl Radin-Norman, LPN, RHIT, CTR, is a Certified Tumor Registrar at Ohio Cancer Incidence Surveillance System (OCISS). She currently serves on the Blog Committee on the OHIMA FY2022-23 Board of Directors. She previously served two years on the OHIMA Board as an Advocacy Project Leader.