Note from the Editorial Director: A CDI spiel

by Melissa Varnavas

Some good friends of mine host an annual costume party for Halloween. My husband and I  know many of the folks who go, but every year there’s a dozen new faces. By way of introduction, the question almost always comes up—what do you do? I usually say I’m a writer and that I work for a healthcare publishing company. People seem to understand that. They can internalize it, tell me what they do in the abbreviated manner that best fits their 30-second spiel, and we can commence with the spooky boogie-oogie.

If you work in the clinical documentation integrity (CDI) profession, you likely have your 30-second spiel down pretty well, too.

“I work in healthcare,” or “I help ensure the medical record is as accurate as possible.” Or “I help physicians understand what they need to write,” maybe “I’m a nurse who now helps treat the medical record,” or “I’m a healthcare coder who helps clinical staff understand how their medical documentation gets used.”

However if you don’t have your spiel down, feel free to steal:

1. I work in healthcare.
2. My background is in [fill in the blank]
3. Then I saw this really cool job where I get to apply my experience and not only help the patients but also the doctors, the hospital, and others.
4. Some days I feel like a private investigator and some days I feel like a translator. Some days I get to be a teacher, so I wear lots of hats.

Take a look back at CDI Week celebrations from years’ past, and you’ll see all sorts of analogies for CDI professionals—superheroes, chefs, frontiersmen. You, who work in this role, do indeed, wear many hats. That’s part of what makes CDI such an interesting career.

At the heart of it, at the most basic level, CDI specialists take their unique clinical and coding skills and use them to look at the medical record with a fresh perspective. They’re looking to find not what the doctor or nurse might see with their own eyes, but what an individual removed from that direct care (for example, an insurance company) might see when only provided with the information in the medical record. CDI professionals look at how the patient’s clinical picture aligns with test results, nurses’ documentation, consult opinions, and physician diagnoses. They ensure that the medical record passed down to others in the healthcare system shows exactly what happened to that patient during his or her point of care. When the information contained in the documentation doesn’t jive (doesn’t get down with the boogie-oogie, so to speak) CDI professionals formulate a question to the provide to clarify the state of affairs.

I use the phrase formulate purposefully, because crafting an appropriate clarification requires a certain skill. Physicians choose their profession to help patients. They study many years and work very hard to ensure they do their jobs well. When another healthcare professional sidles up to let them know their documentation may have a hole or two, some friction may occur.

So, in the early days of their career in CDI, specialists study the Guidelines for Achieving a Compliant Query Practice from ACDIS and AHIMA, they learn the pathophysiology of some of the most common diagnoses (such as respiratory failure, acute-on-chronic heart failure, malnutrition, and sepsis), they learn how to use the International Classification of Diseases-10^th edition-Clinical Modification (ICD-10-CM) and its procedure coding system (PCS). CDI professionals learn why that coding systems matters and how the documentation in the medial record governs how codes get assigned. Furthermore, CDI professionals later learn how healthcare codes—not just ICD-10-CM/PCS but a host of others such as the Medicare Severity Diagnosis Related Groups (MS-DRGs), hierarchical condition categories (HCCs), and evaluation and management (E/M) codes from the Current Procedural Terminology (CPT) code collection—are leveraged by a wide-variety of stakeholders within the healthcare industry. And this perhaps represents one of the broadest perspectives of the importance of the CDI role.

In the United States, our healthcare system leverages coded data for host of reasons. Our hospitals and providers receive reimbursement based on the documentation and resulting codes assigned. The federal government and non-profit agencies study the coded data to evaluate the quality of patient care. Insurers use it to either approve or deny a claim for payment. Scientists use it to study the effectiveness of healthcare treatments. Most recently, codes for social determinants of health  may actually help society move the needle on long-standing issues such as racial disparity, food insecurity, and more.

CDI professionals just starting out in the profession needn’t be overwhelmed by all this. Most new staff members take between three to six months to get the hang of the job—the amount of new information needed to be ingested is so great. Those who do well in the role typically enjoy learning new things—there’s always something new to learn in CDI. Those who love the job, typically love helping others learn something new, too. Those who thrive in CDI, thrive on finding the missing piece of the puzzle and putting a good mystery to rest.

So just what is a CDI specialist anyway? It’s all these things—a multi-costume, multi-hat wearing, amazing professional who seeks to ensure the highest quality of care gets documented in the highest quality manner possible. Superheroes? You betcha! Frontiersmen? Giddy-up! Five-star chefs? C’mon let’s show ‘em what’s cooking!

Looking to see if a career in CDI is right for you? Check out these resources from ACDIS:

• ACDIS Apprenticeship program: Provides those interested in applying for a job in CDI the clinical, coding, and query basics necessary to competently start in the role. It also allows those who complete the online course the ability to use CDI-A as an emblem of their achievement and investment in the profession. The Apprenticeship program includes a quarterly email newsletter with information to help new professionals through their first two years in the job.
• The CDI Specialists’ Complete Training Guide: Walks new professionals through all aspects of the CDI craft, outlining the roles and responsibilities not only of the CDI team but also of those colleagues who the team interacts with on an ongoing basis. The book includes online activities and external readings as well as discussion tips to help new staff have meaningful conversations with their colleagues and managers.
• ACDIS membership: Includes a wealth of materials for those just starting out as well as those with multiple years of practice. Visit the website and poke around—much of what’s up there is free and open to the public. You’ll also find the CDI Journal and sample materials in our Resources section invaluable.

Editor’s Note: Varnavas is the Editorial Director for ACDIS and works closely with our volunteer event planning committee and ACDIS staff on a wide-range of educational and networking events. Contact her at mvarnavas@acdis.org.