Most acute care hospitals have implemented a clinical documentation improvement (CDI) program to drive appropriate reimbursement and clarification of documentation. These roles typically live (and should live) within the HIM department. Clinical Documentation Specialists (CDS) work closely with the medical staff and coders to ensure proper documentation and must have an understanding of coding and reimbursement methodologies along with clinical knowledge.
Certain aspects of the CDI or CDS role require in-depth clinical knowledge and experience to read and understand what documentation is already in the chart and find what is missing. Some diagnoses may be hiding in ambiguous documentation and it is up to the CDS to gather consensus from the medical staff to clarify through front-end queries. There are many tools available to assist in this process by creating worklists and documentation suggestions based on diagnosis criteria and best practices. The focus of CDI is not entirely on reimbursement, although it is a nice reward to receive appropriate reimbursement for the treatment provided while obtaining compliant documentation for regulatory purposes.
Determining or changing the potential DRG prior to discharging a patient provides a secondary data source for many healthcare functions such as case management, the plan of care, decision support, and alternative payment models. For these reasons, a CDS must know the coding guidelines for selecting a principal diagnosis that will ultimately determine the DRG.
Inpatient coders also have the foundational skills to perform this role. Coders and HIM professionals are required to have advanced knowledge of anatomy and physiology, pharmacology, and clinical documentation. Therefore, to answer my original question “Can HIM professionals become Clinical Documentation Improvement Specialists?”, the answer is absolutely. But I will say that it depends on the organization as to whether nursing licensure and clinical experience is required in the job description.
Some organizations have mixed CDI teams consisting of coders and nurses while others may allow only nurses to qualify for this role. The impact of who performs the CDS role in the CDI program all lies in the understanding of the documentation, knowledge of coding guidelines, and detective work to remedy missing or conflicting documentation.
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