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.
