The secret life of a clinical
documentation improvement specialist
By Linda Rene Brown, MA, RN, CCDS, CCRN, CCS, CDIP
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 improve-
ment 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 dont realize
the critical importance of accurate
documentation.
To enter this field, ideally you
should be an RN whos experienced
in acute care, with exceptional criti-
cal thinking skills and the ability to
prioritize and analyze data quickly and
accurately. You should also be comfort-
able 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.
A typical day
Jessie is an RN and a CDIS at Good
Hospital. She starts her day by obtain-
ing the daily inpatient census for new
admissions and discharges. Next, she
prioritizes the medical records shell 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.
10 Lippincotts 2013 Nursing Career & Education Directory www.nursingcenter.com
On Ms. Ss chart, she sees that
Dr.Jones has diagnosed CHF. She
notes that Ms. S has a history of
heart failure, for which she takes lisino-
pril. The chart also reveals a current
brain natriuretic peptide (BNP) level of
2,500 pg/mL, an echocardiogram indi-
cating an ejection fraction of 25%, doc-
umented bibasilar crackles and
peripheral edema, and a healthcare
provider order for I.V. furosemide. BNP
is a biomarker secreted from the ven-
tricle; significant elevations of it can in-
dicate severe heart failure.1
Jessie knows that CHF is consid-
ered a vague and incomplete diagnosis
under Medicare guidelines because it
doesnt accurately or adequately de-
scribe the severity of illness or the risk
of mortality, and she knows that the
medical record contains enough infor-
mation for the healthcare provider to
have made a more complete and thor-
ough diagnosis: acute on chronic sys-
tolic 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 patients 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 wasnt in the final coding.
After she finishes her rounds, she
begins plans for a formal staff devel-
opment session on documentation of
heart failure for Dr. Joness healthcare
provider group.
Why is this career niche needed?
Clinical documentation improvement
is a burgeoning career field thats devel-
oped in response to the Centers for
Medicare and Medicaid Services (CMS)
Diagnostic-Related Group (DRG) sys-
tem. This field really took off after im-
plementation of CMS-DRGs in October
2007. Briefly, the CMS-DRG system as-
signs an International Statistical Classi-
fication of Diseases and Related Health
Problems (ICD-9) code to each inpa-
tient 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 in-
cluding 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 af-
fected a cases DRG and reimbursement
and that the DRG could be maximized
with accurate documentation. Severity
of illness and risk of mortality indica-
tors impacting hospital and physician
grading systems could also be modi-
fied by a more accurate medical re-
cord. Enter the CDIS.
Getting specific
Lets 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 its systolic or diastolic in
origin. You explain to the healthcare
provider that he must document the
diagnosis as acute on chronic sys-
tolic 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 treat-
ing the complicating condition when
its properly documented, and the
hospital is penalized when it isnt.
Another patient has surgery for an
irrigation, which normally cant 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, youve turned a
medical admission into a surgical ad-
mission with a billable OR procedure.
Based on your in-depth knowledge
of both clinical and coding stan-
dards, youll educate the healthcare
provider about the standards and
formulate queries or clarifications,
written requests to correct or improve
the documentation, when the notes
www.nursingcenter.com Lippincotts 2013 Nursing Career & Education Directory 11
in active medical records are unclear
or incomplete.2 Although hospital
coders are permitted to pose queries
retroactively when theyre 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 pay-
ment to the hospital.
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 medi-
cal record. Speaking the language of
healthcare providers, you can com-
municate with them as fellow mem-
bers 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 an-
ticipate 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 diagno-
ses and queries.
Hospitals count on their CDISs
toprotect them from Recovery Au-
dit Contractors (RAC), which are
Medicare-contracted companies look-
ing to recoup money thats 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 docu-
mentation lessens the likelihood of a
RACs success.3
As programs develop and health-
care 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 docu-
mentation 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 Medi-
care fraud and waste.
A completely new coding system,
ICD-10, becomes mandatory in Oc-
tober 2014, bringing a dramatic in-
crease in the specificity of documen-
tation CMS expects from healthcare
providers. CDISs will be invaluable in
helping healthcare providers navigate
the new requirements.
Practical steps to a new career
While formal training isnt usually re-
quired, you may reap great benefits
from enrolling in a coding or CDI
boot camp that helps you learn the
language of coding. You should ex-
pect 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 as-
sociation, the Association of Clinical
Documentation Improvement Special-
ists (ACDIS), which administers the
CCDS credentialing exam to working
CDI specialists. Additional informa-
tion on membership and certification
can be obtained at http://www.hcpro.
com/acdis/. Youll 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 Infor-
mation Management Association
(AHIMA), which also offers the
c ertified documentation improvement
professional (CDIP) credential,
currently maintains an extensive
library of educational resources.
AHIMA can be found at http://www.
ahima.org/.
Weighing the pros and cons
CDISs can be challenged by the com-
plexity of the medical information
theyre reviewing, in learning and ap-
plying the documentation conventions,
and in meeting the need for ongoing
healthcare provider education. Some
healthcare providers resist documenta-
tion 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 continu-
ally, through formal and informal edu-
cation, to assist healthcare providers to
understand specific documentation
topics as well as the global issues fac-
ing healthcare providers to create their
buy-in.4
Because its a relatively new spe-
cialty, the CDI program wont always
be understood by your hospital col-
leagues. As a CDIS, you may be mis-
taken 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 de-
rive considerable satisfaction from the
detective work that reviewing and an-
alyzing a medical record requires.
CDISs usually work standard
business hours and earn salariescom-
petitive with case managers and other
hospital nurses who dont provide
direct care to patients. When you enter
this field, you should be prepared to
work independently withlittle or no
daily supervision. Youshould also be
self-paced and self-directed, extreme-
lydetail-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?
REFERENCES
1. Jessup M, Abraham WT, Casey DE, et al. 2009 Fo-
cused Update: ACCF/AHA Guidelines for the Diagno-
sis 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 Inter-
national 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. Recov
eryAudit 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.
Linda Rene Brown is a clinical documentation improve-
ment consultant with MedPartners HIM in Tampa, Fla.
The author has disclosed that she has no financial rela-
tionships related to this article.