Becoming a CDI professional: Tips for getting started

CDI Journal - Volume 12, Issue 1

Starting a new job can be intimidating, no matter the profession. Whether you’re coming from a clinical or coding background, the CDI role will present new challenges and come with a steep learning curve. Between coding rules and guidelines, query composition and compliance, physician engagement, keeping up with the current medical literature, and the ever-changing world of healthcare reimbursement and regulations, it’s enough to make any newbie’s head spin.

So, if you’re new to the CDI table, this article is for you. The ACDIS team spent time brainstorming and chatting with seasoned CDI specialists to bring you some top-notch tips and ease your transition to this exciting role.

Tip 1: Collaborate with other departments in your facility
New CDI professionals need to ask for, and accept, help and education from others—both inside and outside the CDI department.

“Work together with the coders,” says Amy S. Sterner, CCS, CCDS, CDIP, CDI specialist at Hanover Hospital in Hanover, Pennsylvania. “There is a wealth of knowledge within them, and it is not a competition.”

“Learn to collaborate with others in your facility—coders, case managers, the quality team,” agrees Jennifer Cooper, MHIIM, RHIA, CDIP, CCS, a CDI specialist at Hunt Regional Medical Center in Greenville, Texas. “Although we have different roles, the goal is the same—quality documentation for more efficient care, regardless of the financial impact.”

As you get your feet under you, remember that you don’t have to go it alone. Other departments have valuable information to share with you—you just have to ask.

Tip 2: Gather your resources
Though others at your facility are a great resource as you get comfortable with your new role, individual education can also be beneficial.

“Use every possible minute of orientation,” says Tracy Pitts, RN, BSN, CCDS, CDI specialist at St. Luke’s Hospital in Chesterfield, Missouri. “Explore the references available in your particular program, reviewing diagnoses, associated conditions/complications, decision trees, and coding guidelines.”

Of course, don’t just limit your search for resources to your own organization.

“The first piece of advice I would offer is to join ACDIS and use the numerous resources they offer us,” says Jeff Morris, RN, BSN, CCDS, CDI supervisor at the University of South Alabama Health System. “There are also a ton of free resources available on the internet for new CDI specialists to take advantage of, including from ACDIS if you are unable to join.”

Shannon Huth, MSN, RN, CCDS, CDI specialist at San Francisco General Hospital, reminds new CDI specialists that they need not understand everything right away. “That’s impossible,” she says. “Just take the time to understand your resources: people, books, ACDIS, Coding Clinic, etc.”

Getting buried in books and articles trying to piece it all together could result in frustration, so if you have questions after independent reading, take them to others: your CDI manager, mentor, or co-workers.

Tip 3: Collaborate and network
Reaching outside facility walls can be equally helpful. While different programs may have slightly different focuses, much of the daily CDI work will be consistent between facilities. Knowing what others do daily will help give you a broader perspective on the how and the why of CDI.

“Network, network, network,” says Morris. “Whether you’re two miles or 2,000 miles from another CDI professional, we are all working toward the same goal: attaining accurate documentation reflective of the patient’s severity of illness/risk of mortality and resource consumption. I’ve made so many connections via the ACDIS Forum and the national conference, most of whom I speak with at least weekly to bounce ideas off each other—it’s great to have that support.”

Further, ACDIS local chapters can help you build a network nearby. By attending, you’ll open opportunities for mentorship and networking. (To visit the Local Chapter page, click here.)

“Keep networking,” says Penny Souder, RN, MS, CPC, a CDI specialist at Maui Memorial Medical Center in Hawaii. “Our success depends in part on our ability to network. You are going to encounter some difficulties, but don’t let that encumber you. Each sunrise brings a new journey.”

Tip 4: Give yourself time
You can’t learn everything overnight. As you embark on your new career as a CDI professional, give yourself some time and don’t get frustrated.

“Be patient with yourself!” says Christi Drum, RN, BSN, CCDS, a CDI specialist at Lee Health in Fort Myers, Florida. “CDI is very different from bedside nursing [or coding]. It takes time and exposure to learn and remember the many different facets, rules, regulations, requirements, guidelines, Coding Clinic, etc.”

While on a good day it’s easy to cut yourself some slack, the hard days deserve just as much grace, says Claudine Close, BSN, RN, a CDI specialist at Children’s Hospital at Saint Francis in Tulsa, Oklahoma.

“Don’t take things personally,” she says. “We all have our good days and bad days. Try to remember that the same goes for physicians and residents. Try to start each day with a clean slate.”

Though it’s not always easy, CDI is an exciting field to join, says Diane Smith, RN, CCDS, a CDI specialist at Pen Bay Medical Center in Rockport, Maine.

“Hang in there!” she says. “There’s always something to learn, people to learn from, and conferences to attend. CDI is expanding as we speak, and your opportunities are endless.”

Editor’s note: The advice offered in this article was compiled using ACDIS Meet a Member articles from the past several years. For more information on Meet a Member articles, click here. If you’re interested in being featured in a future article, contact ACDIS Editor Linnea Archibald (

Found in Categories: 
ACDIS Guidance, CDI Expansion