The Catalyst

CDI specialists ensure accurate medical records

By Karen Bridgeman, R.N., CCDS
Clinical Documentation Integrity

What is a Clinical Documentation Integrity specialist?

A CDI specialist reviews the medical record for incomplete, ambiguous or conflicting information. Their role is to help ensure that the medical record accurately captures the patient’s condition, ensuring that the severity of illness and risk of mortality is maximized for the patient.

Registered nurse and CDI specialist Tina Smith, third from left, round with, Drs. Savanna, Dincman, from left, Lisa Hunt, Jennifer Jaroscak Andrea Whitfield and Becky Cafiero. MUSC currently has 12 CDI specialists. Photo provided.
Registered nurse and CDI specialist Tina Smith, third from left, round with, Drs. Savanna, Dincman, from left, Lisa Hunt, Jennifer Jaroscak Andrea Whitfield and Becky Cafiero. MUSC currently has 12 CDI specialists. Photo provided.

When documentation in the medical record is incomplete, ambiguous or conflicting, the CDI specialist must seek clarification by asking the medical team to provide clarification. The CDI specialist is the liaison between the medical staff and the coding department, as they strive to have the most accurate and complete medical record available for coding.

They must abide by the coding and reporting regulations set forth by the Centers for Medicare & Medicaid and the National Center for Health Statistics using the International Classification of Diseases, ninth revision. 

Who are CDI specialists?

An important characteristic for a specialist is to possess a strong clinical background with the ability to critically think, as the specialist needs to recognize treatments and documentation that are not clearly documented in the medical record.

MUSC began its CDI program in 2005 with two nurses. The specialist initially reviewed only the Medicare population with an emphasis on reimbursement. The program expanded in 2007 and has grown to 12 CDI registered nurses. There are nine CDI nurses who do concurrent reviews, physician education and rounding with the medical team, along with two CDI nurses who review records after discharge for unanswered queries and coding discrepancies. The reviews have expanded to include a large percentage of the MUSC patient population.

In 2009, the emphasis shifted from reimbursement to quality. This ensures that MUSC patients use a severity of illness and risk of mortality system to provide greater detail of a patient’s condition and the care. To reflect this change of focus, the MUSC CDI department changed its name from Clinical Documentation Improvement to Clinical Documentation Integrity. This change reflects the belief that documentation must uphold the standards for accuracy as well as veracity. The CDI program expanded further in 2012 by initiating the Pediatric CDI program, including the neonatal ICU and Level 2 nursery.

The CDI specialists include Tina Smith, R.N., and Pam Parris, R.N., who both have been with the MUSC program from the beginning. Others include registered nurses Jackie Robinson, Randy Massingale, Cindy Kicklighter, Marsha Cisa, Marilyn Willis,  Priscilla Browder, and CDI manager Sylvia Odom.

The CDI staff serves on a variety of hospitalwide committees, including the Hospital CDI Committee, Pediatric CDI Committee, Clinical Integration Committee for ICD-10 (Physician Education), Hospital Forms Committee, and the EPIC build team. 

Why is the CDI specialist role emerging?

Registered nurse Jackie Robinson, CDI specialist, reviews a medical record. Photo provided.
Registered nurse Jackie Robinson, CDI specialist, reviews a medical record. Photo provided.

According to the Association of Clinical Documentation Improvement Specialists, the growth of the CDI specialist profession has mirrored the health care industry’s increased focus on compliance with regulations, managed care profiles, payment for services rendered and liability exposure. All these factors are increasingly dependent on the integrity of complete and specific clinical documentation in the medical record.

With the implementation of ICD-10 [a coding system change for medical diagnosis], set to begin Oct. 1, 2014, there will be additional documentation specificity that the CDI specialist will need to ensure is documented in the medical record. The current ICD-9-CM has 24,000 codes; whereas, ICD-10-CM/PCS has more than 150,000 codes. This will increase specificity and capture a more accurate picture of the patient’s condition and care. Capturing this data will more accurately demonstrate disease trends, improve health care and assist in clinical research.

The Certified Clinical Documentation Specialist credential has been created to recognize, support and identify a high level of experience as a mark of distinction of CDI specialists demonstrating proficiency and knowledge in clinical documentation improvement. 

Why is a week of national recognition needed?

  • To recognize the skills and expertise of Clinical Documentation Integrity specialists
  • To increase public awareness of the CDI profession
  • To positively affect the personal and organizational performance of CDI specialist
  • To provide broader education on the importance of the quality connection of documentation of care

A work group supported by the Association of CDI Specialists declared that the Clinical Documentation Improvement Week will occur annually during the third week of September. This year, it is Sept. 15 - 21.

September 20, 2013
 
 
 

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