Revenue Cycle February 16, 2022

An Expert’s Perspective on Becoming a Clinical Documentation Integrity Professional

Clinical Documentation Integrity (CDI) is a key cog in the patient treatment process but remains relatively unknown in the larger healthcare spectrum. We spoke with Karen Newhouser, of AMN Healthcare Revenue Cycle Solutions, to outline the CDI profession and how an RN can successfully transition to a CDI career.

What is a Clinical Documentation Integrity Professional?

First, it is important to note that CDI is not restricted to RNs—while most CDI professionals are RNs, other healthcare professions can be successful in CDI with the right skillset. In fact, Newhouser uses “CDI Professional” as the preferred nomenclature for the role, since it isn’t a sub-specialty of a specific field but its own profession, open to qualified personnel from different foundational backgrounds.

As for the role of a CDI professional—simply put, “they bridge the gap between provider documentation and healthcare code assignment.” Of course, the work that goes in to bridging the gap is more complex. When a patient visits a provider in any setting—an office, hospital, or rehab center, for example—the provider documents the visit, detailing their medical decision making surrounding the patient’s signs/symptoms, and any other relevant information from the visit.

Once the patient leaves, the health record is forwarded to a healthcare coder for code assignment. “A code is a representation for the documentation—diagnoses, signs, symptoms, co-morbid conditions, other information, as well as procedures or treatments that were performed—are assigned codes,” Newhouser says. “And those codes get used in various ways.” One purpose of these codes is for research—“for example, data from healthcare codes assigned to documentation of patients with COVID-19 have helped drive initiatives and resource allocation during the pandemic,” Newhouser continues. Another fundamental purpose for codes is appropriate billing. Whatever their purpose, healthcare codes must reflect precise documentation of the patient’s current health status via proper code assignment.

Since code assignments may not always precisely reflect the patient’s health status due to documentation that may need clarification, there needs to be a go-between to bridge the two. That’s where CDI professionals come in. “The CDI professional’s role is to look for that gap in the documentation—are there indicators in the health record that show a piece of the documentation could be more thoroughly explained or can be further specified—for example, there could be one general code to describe a condition, but there could be 25 more specific codes.” Thus, a CDI professional forms the key cog in the process from the patient to the documentation, to the final coding.

Why Become a CDI Professional?

Being a unique field in the fact that it presents no formal schooling, CDI finds new professionals for a variety of reasons. For Newhouser, a CDI role presented itself naturally when she was a case manager performing utilization review.

When her facility opened a dedicated CDI role, she jumped at the opportunity. “It advanced my clinical skills in a unique manner,” Newhouser says, “because I was utilizing my critical thinking skills from a different point-of-view—what is the patient’s health status, what are the health record documenters saying—putting all the pieces of the documentation, of the patient’s health record into place and bridging that gap.”

For other professionals, namely nurses, the CDI role might be born from seeking something different in their healthcare careers—new challenges or a change of scenery, for example. Additionally, with the pandemic moving many CDI roles to remote settings, professionals who flourish in a remote environment might find CDI an attractive opportunity—particularly those with disabilities. For “nurses who have hurt their backs or suffered work-related disabilities, or have physical challenges,” a remote CDI position might be something to explore.

CDI Professional Qualifications

While most hiring facilities seek out some form of training for the role, there are no formal qualifications required to become a CDI professional. Depending on need, some hospitals may take nurses off the floor and train them for a CDI role.

There are various organizations and programs that offer CDI training for RNs and other professionals seeking development. The Association of Clinical Documentation Integrity Specialists (ACDIS) is the largest and most well-known CDI organization, offering paid membership along with a litany of free material to reference.

Becoming a member of ACDIS comes with incentives, including free CEUs, discounted admission to annual conferences, and access to CDI certifications. “They have certifications for both inpatient and outpatient CDI,” Newhouser says, the CCDS for inpatient and the CCDS-O for outpatient certification. Both certifications require two years of experience in CDI to sit for the exam.

AMN Healthcare Revenue Cycle Solutions also has a CDI Academy that includes lessons for aspiring CDI professionals. Though these programs don’t come with a promise of employment, they are vital avenues toward CDI skill development and success within the field.

Keys to Success

As mentioned above, there are multiple platforms with which to gain a better understanding of the CDI role but there are innate skills that play heavily into the daily functions of the job. “To be a successful CDI professional today, you need to have knowledge of healthcare coding,” Newhouser says, “because you can’t bridge a gap if you don’t know both sides of the gap.”

While most formal CDI programs, including ACDIS and AMN Healthcare Revenue Cycle Solutions, have basic coding knowledge as a part of the curriculum, there are also opportunities to attend coding school. “Some community colleges offer one-year certificate programs on healthcare coding, so that part of the CDI role can be obtained through formal schooling.”

Advice for Prospective CDI Professionals

For nurses exploring a transition to a CDI career, the best source of insight is often from professionals currently working in the field. “I would seek out CDI professionals within their place of employment,” Newhouser says. Since most hospitals have CDI professionals on staff, this is an efficient avenue to hear their perspective on the role.

Another avenue for prospective CDI RNs to gain valuable information about the role is through shadowing a CDI professional for a day. Shadowing is an effective and practical orientation to the role, allowing nurses to find out if it’s a real fit for them through their own observations.

Newhouser also calls back to the plethora of online resources available. “Jump on the ACDIS website and absorb as much information as you can—they offer blogs and chat rooms to gain insight on the CDI role,” as well as other platforms to connect with professionals along with other materials. The bottom line, “seek out other people in the role to network with and get as much information as you can about the role.”

As a nationwide organization, ACDIS also has local chapter meetings for CDI professionals to attend. Seeking to attend a chapter meeting is an excellent opportunity to gain further perspective from CDI professionals. “I recommend the person who wants information about the CDI role to talk to as many people as they can,” Newhouser says.

Explore Additional CDI Resources

  • HCPro - The publishing arm of ACDIS, offering written materials

Are you an RN interested in a career as a CDI professional? Learn more about CDI educational opportunities at AMN Healthcare Revenue Cycle Solutions.

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