Five cents of a quarter: CDI from a nonclinical background
by Carolyn Riel
It’s common to see CDI job listings that require applicants to be registered nurses. Often an RN credential is not listed as being “preferred,” but required. There are risks, however, with only seeking candidates from this one background.
“The risk of not having a team from diverse backgrounds is simple: Your department will fail,” says Angelica Naylor, MBA, BSN, RN, CCDS, CDI consultant and manager with CorroHealth, based in Plano, Texas. “If not complete failure, your CDI department will at least not perform at optimal level or near the outcomes of diverse CDI departments.”
“It’s not just the clinical side of things that matters,” adds Monica Tyiska, MBA-PM, RHIA, CCS, CPC, CPMA, CHA, OHCC, CCP-P, coding/CDI manager at CentraState Healthcare System in Freehold, New Jersey. “It’s how the clinical side relates to the coding side; both sides need to learn from each other, but ICD-10 has forced more coders to better understand the clinical side.”
Nonclinical professionals in CDI
Tyiska first became aware of CDI when working for an organization that was outpatient focused. There, she worked as a coding professional before moving into the coding education department. At that point, she joined ACDIS because its tools helped her with auditing providers who were selecting their own codes in the EHR. By joining ACDIS, she also became aware of what CDI truly meant.
While many people assume that she’s not clinical, Tyiska points out that, particularly with the change from ICD-9 to ICD-10, coding and CDI professionals alike must possess clinical knowledge in order to properly understand the pathophysiology and anatomy presented in a chart.
“As a coder, I wasn’t trained on a lot of clinical aspects, so I have to take those extra steps on my own to have that knowledge,” she says. “People make the same assumptions of me as they do other coders and even foreign-trained physicians. They think that we don’t know what we’re saying or talking about without listening to us speak.”
Like all CDI professionals, Tyiska often finds herself needing to approach providers through the query process for elaboration on the patient’s documented condition. In order to ensure she understands the complete clinical picture, Tyiska puts in the extra legwork to research before approaching a physician.
“I may have to do another lap around the park to make sure I get everything clinical,” she says. She adds that people coming from a clinical background should be doing just as much legwork—in the coding direction. “I need the clinical people to realize when they have to do an extra lap to understand the coding side. Coding is [telling] the whole story of the patient.”
While Tyiska’s conversations with providers include the clinical nuances of a patient’s case, CDI education for physicians needs to ensure that the patient record doesn’t just stay in the clinical bubble. Other people will be looking at it and need to understand the story of the patient as well. As important as the clinical side of a patient record is, the coding side is what leads to accurate reimbursement, quality scores, and population health data.
“I tell clinical folks that if we made up a quarter, then I’m the nickel,” Tyiska says. “Taking care of the patient is the most important thing and it’s the 20 cents, but I’m the extra five.”
Advocate for change, education
When the previous CDI manager transitioned to the denials management department, Tyiska went to her boss to advocate for herself and discuss taking the open position. Fortunately, her boss understood that CDI isn’t solely focused on either the clinical or the coding side of things. With her new role, Tyiska brought the CDI and coding departments together and kept them in the same circle.
In meetings with both groups, Tyiska says that each person has their chance to share their perspective because team members need to understand what everyone sees.
“Coding learns more of the clinical aspects, and CDI can also understand the coding rules that they need to be aware of,” she says. “There are also payer guidelines that we have to be aware of, and since we’re all in one bubble we can keep that communication going.”
While some advocate that clinical knowledge is essential for CDI professionals, Tyiska points out that the coding piece is also vital and keeps your reviews from being lopsided. Coding professionals in CDI often feel they have to prove their clinical knowledge, but those from a clinical background don’t often feel the need to prove their coding knowledge.
“I have seven certifications, in auditing, coding, compliance, and others, and that’s because I understand the full circle is needed,” Tyiska says. “I know I need to prove I’m capable.”
Those entering the CDI field from a nonclinical background certainly need to put in the work to learn the clinical nuances required for solid record reviews, but they aren’t the only ones who should strive for constant education and growth.
If you hail from a clinical background, you “should build your coding and understand what you have to understand,” Tyiska says. “What I mean by that is, you don’t know what you don’t know when you load up on just clinical.”
If CDI departments are only hiring people with a clinical background or RN credential, they won’t be aware of where they could improve by having perspectives from different experiences and backgrounds.
Address hiring practices
The first step to including nonclinical, diverse educational backgrounds in your department is ensuring that your job descriptions reflect that desire.
“I have seen job descriptions and ads written with qualifications requiring clinical credentials only, such as RNs or physicians, and only some listings have some required coding credentials, like RHIA or RHIT,” says Naylor. “I have seen CDI job descriptions that require clinical RNs to have a background in critical care nursing. As a former hiring manager, part of me understands why; however, I did not include this restriction in the job description because there are great and exceptional nurses with medical/surgical experience.”
Naylor suggests that in a job listing, it is better to list experience, such as critical care or utilization backgrounds, or even credential types, such as CCDS, CCS, or CDIP, as preferences rather than requirements. If you require candidates to have these specific credentials, you will minimize the already limited number of CDI applicants.
Having a pool of candidates with varying experience and credentials is important for a well-rounded CDI department that can support the process from the start of a chart review all the way to denials defense. For example, CDI professionals with coding experience contribute knowledge to the auditing team and can be a valuable asset in dealing with denials.
A diverse CDI department “enhances the team by maximizing potential, capitalizing on the incredible strengths that both groups bring to the team, and brings a balance of perspectives to the CDI team,” Naylor says. “Write job descriptions to include HIM professionals. Benchmark your CDI department against those CDI departments that consist of clinical and HIM credentials and make the necessary adjustments.”