I recently talked with a colleague on the phone who has been out of work for over a year now, this despite the fact the economy is performing well on all major indices. Now, granted my colleague has her age going against her as a strong headwind, she has been actively searching for a book-keeping related position day in and day out with little results. My colleague has been a bookkeeper for over twenty-five years with a very stable work history, having been at her last employer, a construction company, for nearly twenty-years. Even more recently, I heard from a friend that her daughter was out of work for about six months going on seven, was let go from her coding and billing position at a large physician practice, off shoring of jobs overseas where labor is more “cost effective.” Recollecting on these stories, there is a common theme that is worthy of note undoubtedly explaining the individual’s difficulty in landing a new opportunity.

Complacency Breeds Staleness-Limiting Opportunities

Complacency is defined by Merriam-Webster as self-satisfaction especially when accompanied by unawareness of actual dangers or deficiencies. Certainly, complacency plays a major role in these individual’s challenges in locating suitable employment. Fundamental to success in any career is the commitment to continual growth and ongoing development, recognizing that resting on one’s laurels is a long-term strategy with numerous perils and dangers. Increased emphasis on automation and enhanced efficiencies created by computer software and systems is one major threat as well as offshoring of service related jobs. In order to circumvent and mitigate these real threats, one must invest in their careers with development and creation of a clear organized plan for furthering their knowledge, skill sets and core competencies in his/her line of work. And when I reference further education and training, I am not referring to solely focusing upon achievement of the requisite CEUs to maintain any credentials earned associated with their line of work. Instead, I am referring to going well beyond the minimum standards of continued education and training to maintain one’s present position in the company.

Going Beyond the Call of Duty-Clinical Documentation Integrity

Clinical Documentation Improvement Specialists as a profession and industry have existed for ten plus years focusing primarily on the capture of diagnoses for severity of illness and quality score reporting in addition to the capture and solidification of diagnoses impacting reimbursement, hospital acquired condition and patient safety indicator reporting. While these elements are crucial for hospital operational financial performance, CDI specialists must recognize the immediate need to grow their professional career in CDI by expanding their core knowledge, skill sets and core competencies, acquiring and accelerating their breadth and depth of knowledge in all facets of effective documentation and communication of patient care. The fact of the matter is all functions of the revenue cycle, defined by HFMA as “All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue” are directly dependent upon the quality, accuracy and completeness of the documentation serving as a communication tool for fully informed quality focused patient centered outcomes based financially solvent healthcare delivery models.

Rather than focus upon diagnoses capture through the verbal and written query process supplemented by diagnosis driven physician documentation education, instead expand the direction of CDI to include partnering with other departments such as case management, utilization review, quality, risk management, the business office and patient financial services in a collaborative manner. Understand and appreciate the challenges and hurdles each department faces in fulfilling and properly executing their roles, duties and responsibilities in the revenue cycle. Addressing these challenges and hurdles requires an expanded deep understanding of best practice standards and principles of documentation that we can begin to incorporate into our regular daily practice of chart reviews and instructional interactions with our constituent physicians. Getting to this stage requires the willingness to commit to self-learning, self-discipline, motivation and willingness to stay the course in terms of investing the time and energy to grow your professional career in CDI. I call this “Life-Long Learning” that extends indefinitely to meet the profession’s needs and requirements.

Moving Ahead

Don’t rest on your current laurels in skill sets of clinical documentation improvement as the need for complete and accurate communication of patient care continues to evolve with the changing reimbursement methodologies of healthcare. Securing diagnoses currently is and will remain just a small although important part of the documentation improvement process moving forward. Begin to set out on the long journey to build and grow your career in CDI with longevity by equipping yourself for the future to best compete in the CDI profession. Many colleagues have reached out to me and inquired how to expand their breadth and depth of knowledge in identifying and recognizing insufficiencies in clinical documentation and how to effectively convey the message and make a compelling case for complete and accurate documentation to the physician while building credibility and respect for knowledge in true documentation integrity. Much of what can be accomplished in this area can be learned through exhaustive reading of medical journals that often time contain pertinent articles on documentation, signing up for Medicare Open Door Forums, signing up for your local Medicare Administrative Contractor list-serves, signing up for MLN Matters list-serves, and investing in Bates Guide to H & Ps. Many of the major medical schools have residency geared modules/articles and tutorials on teaching points for clinical documentation and charting that I always find helpful. The most important point is establishing a date to start, remain motivated and committed to continual learning in CDI beyond CME requirements, invest in yourself, be confident and you will get where you need to be. Leave complacency in CDI behind, invest in your long tenured career through a proactive approach to ongoing learning and growth. Never forget this adage: “Look Out for Number One, No One Else Will.”