Clinical Documentation Integrity ~ An Intro

Worthy Endeavors Inc provides multiple services but at its core is clinical documentation integrity.

What is “clinical documentation integrity”?

Clinical documentation integrity is ensuring that documentation translates across all perspectives and disciplines to accurately reflect the experience of the patient.

What do we mean when we say, all perspectives and disciplines?

There are 5 perspectives/disciplines:

  1. Reimbursement
  2. Quality
  3. Medical Necessity
  4. Risk Adjustment
  5. Coordination of services

There is a lot of information and documentation to keep track of which is why specific departments within an organization specialize in each of these disciplines and perspectives. Each department has staff who review medical records then apply the rules of their discipline to the documentation.

When the best documentation is achieved, reimbursement is appropriate, quality reporting is accurate, level of care assignment is accurate, risk adjustment scores are accurate, and post-acute care services are medically necessary and appropriate.

To ensure the best documentation is achieved Clinical Documentation Integrity is housed in many different locations within an organization. The most typical areas are Health Information Management (HIM), Revenue Cycle, Quality, or Case Management. How the healthcare system is organized will determine the focus and priorities of a Clinical Documentation Integrity department.

The guiding principle of every clinical documentation specialist should be to seek the “clinical truth”.


Who performs the work of the CDI Specialist?

The clinical documentation specialist can come from a variety of backgrounds in healthcare. These include but are not limited to nursing, coding, HIM, and international medical graduates. The degrees and credentials that the CDI specialist might enter the field can include RN (Registered Nurse), CCS (Certified Coding Specialist), CPC (Certified Professional Coder), RHIT (Registered Health Information Technologist), RHIA (Registered Health Information Associate), or IMG (International Medical Graduate). Again, this is not an exhaustive list of persons who engage in clinical documentation integrity efforts, but a broad overview of the some of the more common backgrounds of persons working in the field.

After a person has gained experience as a clinical documentation integrity specialist, they can seek certification to demonstrate their proficiency in their knowledge and skill level in the field. The two most common CDI credentials in the field currently are the CCDS from ACDIS and the CDIP from AHIMA. I have included some brief information about the two organizations below with links to their websites.

Professional Resources

ACDIS (Association of Clinical Documentation Integrity Specialists) – a professional organization dedicated to CDI, which is the home of the CCDS certification (Certified Clinical Documentation Specialist), and the CCDS-O certification (Certified Clinical Documentation Specialist – Outpatient).

AHIMA (American Health Information Management Association) – a professional organization which offers the CDIP certification (Certified Documentation Integrity Professional). Additionally known for CCS certification (Certified Coding Specialist), which is the certification for inpatient coders.

How does someone get started in the CDI Specialist role?

It does seem like there is a high demand for experienced CDI specialists, but not a huge supply of experienced CDI specialists, so the industry does need new people to enter the field. Most of the CDI specialists I have met over the years have all started in the profession working within the healthcare organization they had been originally working at in another capacity. They had expressed an interest in becoming a CDI specialist and contacted the department at their organization. Although there might not be an opening when they originally inquired, their initiative and interest made the hiring manager aware, so that once a position opened, they could then apply for the position.

There had been a movement towards remote work prior to the pandemic, but once the pandemic happened, EVERYONE pushed towards remote CDI work. Because much of the work is done remotely, theoretically, a person could get their first CDI job working for an organization outside of their local healthcare system, but I think is not likely. The reason I say this is because since the pandemic has happened, there has been the “mass exodus” to leave the bedside, so a tremendous number of nurses have been seeking remote work positions. The number of applications for any job posting that is remote and does not require experience has been large.

In fact, while I was hiring RN reviewers for a large project, I became acquainted with a blogger by the name of Nurse Fern, whose platform helps nurses find remote jobs. Half of the applicants had found our job from her. For anyone trying to get started in CDI, my main advice would be perseverance, as the right opportunity might not present itself immediately. While you are waiting for that opportunity, learn everything can about CDI, coding, quality, medical necessity, and risk adjustment. You will be that much more prepared for when you do get your opportunity to get started.

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