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doi: 10.1097/01.NURSE.0000426541.97687.87
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The secret life of a clinical documentation improvement specialist

Renée Brown, Linda MA, RN, CCDS, CCRN, CCS, CDIP

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Author Information

Linda Renée Brown is a clinical documentation improvement consultant with MedPartners HIM in Tampa, Fla.

The author has disclosed that she has no financial relationships related to this article.

ARE YOU a sharp, analytical nurse with a strong bedside background, a head for business, and a passion for language and precision? As an RN clinical documentation improvement specialist (CDIS), you could be the vital link between the world of inpatient coders who translate diagnoses into data, many of whom have no patient care background, and the world of healthcare providers and nurses, many of whom don't realize the critical importance of accurate documentation.

To enter this field, ideally you should be an RN who's experienced in acute care, with exceptional critical thinking skills and the ability to prioritize and analyze data quickly and accurately. You should also be comfortable teaching in group settings and on the fly because a large part of the job is educating healthcare providers about current documentation standards and helping them appreciate their role in documentation improvement.

If this field seems like a good fit, read on to discover more about this new and growing field.

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A typical day

“Jessie” is an RN and a CDIS at Good Hospital. She starts her day by obtaining the daily inpatient census for new admissions and discharges. Next, she prioritizes the medical records she'll be reviewing. She rounds on the nursing units, reading each medical record, picking up additional clues by talking to the staff, and creating worksheets for each patient.

On Ms. S's chart, she sees that Dr. Jones has diagnosed “CHF.” She notes that Ms. S has a history of heart failure, for which she takes lisinopril. The chart also reveals a current brain natriuretic peptide (BNP) level of 2,500 pg/mL, an echocardiogram indicating an ejection fraction of 25%, documented bibasilar crackles and peripheral edema, and a healthcare provider order for I.V. furosemide. BNP is a biomarker secreted from the ventricle; significant elevations of it can indicate severe heart failure.1

Jessie knows that “CHF” is considered a vague and incomplete diagnosis under Medicare guidelines because it doesn't accurately or adequately describe the severity of illness or the risk of mortality, and she knows that the medical record contains enough information for the healthcare provider to have made a more complete and thorough diagnosis: acute on chronic systolic heart failure. She leaves a written query on the medical record, asking for specificity of the diagnosis, and talks to Dr. Jones when she sees him on the nursing unit, explaining how CHF should be documented and how it affects severity of illness, length of stay, and hospital reimbursement.

As she continues her rounds, Jessie asks a nurse to document the stage of a patient's ulcer noted on an admission skin assessment. Seeing the dietitian in the hall, she asks about malnutrition in a patient starting parenteral feedings.

Later, she pages a surgeon to ask for a clearer description of the “I&D” (incision and drainage) she noticed in the operative note. She e-mails one of the inpatient coders about a discharged patient whose dissected artery wasn't in the final coding.

After she finishes her rounds, she begins plans for a formal staff development session on documentation of heart failure for Dr. Jones's healthcare provider group.

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Why is this career niche needed?

Clinical documentation improvement is a burgeoning career field that's developed in response to the Centers for Medicare and Medicaid Services (CMS) Diagnostic-Related Group (DRG) system. This field really took off after implementation of CMS-DRGs in October 2007. Briefly, the CMS-DRG system assigns an International Statistical Classification of Diseases and Related Health Problems (ICD-9) code to each inpatient diagnosis and procedure and groups the case into one of 745 DRGs. Each DRG is assigned its own relative weight and geometric length of stay. Relative weight is used to determine payment because all the diagnoses in any given DRG are assumed to use about the same degree of resources. DRGs can be adjusted upward by including documentation of major and minor comorbidities, or by shifting the principal diagnosis to one that leads to reimbursement for a higher intensity of illness and more care required.

Hospital administrators quickly realized that the diagnosis chosen affected a case's DRG and reimbursement and that the DRG could be maximized with accurate documentation. Severity of illness and risk of mortality indicators impacting hospital and physician grading systems could also be modified by a more accurate medical record. Enter the CDIS.

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Getting specific

Let's see the effect of inaccurate codes. A patient whose principal diagnosis is acute renal failure will fall into DRG 684, Renal Failure. If this patient also has signs of decompensating heart failure and the healthcare provider documents “CHF,” the hospital staff may expend time and resources treating this problem without it being reflected in the DRG. CMS expects the provider to indicate whether heart failure is acute or chronic, and whether it's systolic or diastolic in origin. You explain to the healthcare provider that he must document the diagnosis as “acute on chronic systolic heart failure” to meet the CMS documentation standards. The DRG becomes 682, Renal Failure with Major Comorbidity, which indicates a higher severity of illness and a higher relative weight due to the increased resources needed to treat the patient. The correct diagnosis provides a greater reimbursement and longer expected length of stay. The hospital is rewarded for diagnosing and treating the complicating condition when it's properly documented, and the hospital is penalized when it isn't.

Another patient has surgery for an “irrigation,” which normally can't be billed by the hospital. When you talk to the surgeon and learn that she actually performed an excisional debridement, then show her how to document that in the medical record, you've turned a medical admission into a surgical admission with a billable OR procedure.

Based on your in-depth knowledge of both clinical and coding standards, you'll educate the healthcare provider about the standards and formulate queries or clarifications, written requests to correct or improve the documentation, when the notes in active medical records are unclear or incomplete.2 Although hospital coders are permitted to pose queries retroactively when they're working with the discharged medical record, the record is more likely to come under scrutiny when entries to the medical record, particularly those that may increase reimbursement, are made after the patient is discharged. In addition, the coder must hold the medical record for final billing until the query is answered, delaying payment to the hospital.

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Clinical experience a plus

Although some CDI programs employ coders as CDI specialists, you, as a nurse clinician, can offer a unique perspective with clinical experience to support your analysis of the medical record. Speaking the language of healthcare providers, you can communicate with them as fellow members of the clinical team. Looking at progress notes, consultant reports, medication records, lab values, and radiology reports, you draw on your nursing background to predict or anticipate the diagnoses of patients being treated, and use your knowledge of coding rules to help the healthcare providers choose the right words to describe the diagnoses in CMS-friendly terms. You also work closely with other disciplines such as nursing and dietary, whose documentation helps support healthcare providers’ diagnoses and queries.

Hospitals count on their CDISs to protect them from Recovery Audit Contractors (RAC), which are Medicare-contracted companies looking to recoup money that's already been paid to the hospital, and to help them maintain positive scores with grading agencies and government entities that evaluate hospitals for the public. Complete and accurate documentation lessens the likelihood of a RAC's success.3

As programs develop and healthcare reform takes shape, the scope of practice of the CDIS continues to expand. Some hospitals have asked their CDISs to formulate queries for core measures, hospital-acquired conditions, patient safety indicators, quality indicators, and any other areas that can be enhanced through good documentation. Compliant documentation that neither overstates nor understates the severity of illness and resource utilization is a critical tool in shielding hospitals and healthcare providers from allegations of Medicare fraud and waste.

A completely new coding system, ICD-10, becomes mandatory in October 2014, bringing a dramatic increase in the specificity of documentation CMS expects from healthcare providers. CDISs will be invaluable in helping healthcare providers navigate the new requirements.

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Practical steps to a new career

While formal training isn't usually required, you may reap great benefits from enrolling in a coding or CDI “boot camp” that helps you learn the language of coding. You should expect a structured orientation program from your hospital.

Certification is available for the experienced CDIS. At this time, the principal certification credential is through the CDI professional association, the Association of Clinical Documentation Improvement Specialists (ACDIS), which administers the CCDS credentialing exam to working CDI specialists. Additional information on membership and certification can be obtained at http://www.hcpro.com/acdis/. You'll also find multiple educational materials and networking opportunities for members at this site.

The Association for Integrity in Health Care Documentation (AIHCD) offers certification as a C-CDI to those who complete its training module; visit its site at http://www.aihcd.com/.

Finally, the American Health Information Management Association (AHIMA), which also offers the certified documentation improvement professional (CDIP) credential, currently maintains an extensive library of educational resources. AHIMA can be found at http://www.ahima.org/.

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Weighing the pros and cons

CDISs can be challenged by the complexity of the medical information they're reviewing, in learning and applying the documentation conventions, and in meeting the need for ongoing healthcare provider education. Some healthcare providers resist documentation improvement efforts. They may not recognize the importance of their documentation, become defensive about having their documentation questioned, or dismiss CDI programs as just a money-making effort. To meet these challenges, CDISs work continually, through formal and informal education, to assist healthcare providers to understand specific documentation topics as well as the global issues facing healthcare providers to create their buy-in.4

Because it's a relatively new specialty, the CDI program won't always be understood by your hospital colleagues. As a CDIS, you may be mistaken for a case manager or coder, but each encounter brings an opportunity to educate your listener. On the plus side, you can generally expect to derive considerable satisfaction from the detective work that reviewing and analyzing a medical record requires.

CDISs usually work standard business hours and earn salaries competitive with case managers and other hospital nurses who don't provide direct care to patients. When you enter this field, you should be prepared to work independently with little or no daily supervision. You should also be self-paced and self-directed, extremely detail-oriented while understanding the big picture, able to manage and prioritize a shifting caseload, and comfortable with frequent change.

The career of a CDIS is demanding but the rewards are considerable. Are you ready for the challenge?

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REFERENCES

1. Jessup M, Abraham WT, Casey DE, et al. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation Circulation. 2009;119(14):1977–2016

2. Bowman S, Smith PC, DeVault K, et al. Managing an effective query process J AHIMA. 2008;79(10):83–88

3. Centers for Medicare and Medicaid Services. Recovery Audit Program. 2012. http://www.cms.gov/recovery-audit-program/.

4. Robinson S. The art of physician communication. 2010. http://www.hcpro.com/content/253291.pdf.

© 2013 Lippincott Williams & Wilkins, Inc.

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