Highly Proficient Clinical Documentation Integrity Specialists

A fully engaged Clinical Documentation Integrity Specialists possesses an open mind, is inquisitive, has an insatiable appetite for continual learning in all aspects of physician documentation, commits to maintaining relevancy in clinical medicine and standards of documentation, and subscribes to the philosophy of continuous quality improvement. A highly proficient Clinical Documentation Integrity Specialists is not content with the status quo and is always searching out and suggesting ways to embark on process improvement initiatives.

Skill Sets and Knowledgebase of A CDI Professional

A strong foundation for progression to an “Advanced CDI Professional” include working knowledge of the MS-DRG reimbursement methodologies such as principal diagnosis, secondary diagnosis, CC/MCC capture, solid clinical knowledge, compliant query generation practices, and ability to communicate with physicians and other providers both written and verbal. In addition, a proficient CDI professional is a master of time management, exemplifies critical thinking skills, and is capable of engaging physicians in all CDI initiatives as willing participants versus simply targets of repetitive queries. An Advanced CDI professional embraces and capitalizes upon the opportunity to grow one’s career beyond that of traditional CDI.

The following attributes representing knowledgebase, skill sets, and core competencies are center to making the transition to an advanced CDI professional:

• Strong knowledge of best practice standards and principles of documentation to effectively communicate patient care
• Expansive clinical knowledge acumen with commitment to expansion through participation in clinical education opportunities such as reading of journals and a wide array of articles that appear in the JAMA and the NEJM to name just two highly respected publications
• Encompassing knowledge of up-to-date pertinent documentation changes impacting physicians and all providers with the ability and commitment to share consistently with providers
• Serves as a conduit for all physicians and other providers on payer ever changing requirements for documentation impacting compliant documentation, coding, and billing practices
• Desire and commitment to working with other hospital departments in a collaborative coordinated fashion in the name of achievement of true clinical documentation excellence
• Willingness to embrace the support the need for transformation of current repetitive, reactionary, transactional CDI processes consisting of query generation
• Recognizes and subscribes to the philosophy of the medical record as a communication tool versus a reimbursement tool, always putting the communication of patient care first and foremost
• Recognizes and treats CDI software as a solution and not a crutch for documentation integrity
• Possesses a business mindset in all aspects of CDI, recognizing that a CDI professional is a businessperson focusing upon continually improving business processes to achieve clinical documentation excellence
• Subscribes to the philosophy of CDI as a calling and role versus today’s model with a tendency toward CDI as a job and a paycheck

I challenge all CDI professionals to join me in the crusade to transform CDI to one that promotes, advocates for, and achieves true clinical documentation excellence through thought processes that incorporate a mindset of proactive denials avoidance documentation as opposed to chasing diagnoses that are often refuted based upon clinical validation. Doing the same thing in CDI over and over and expecting different results is a lesson of futility that has proven its ineffectiveness in present day CDI processes.