Guest Post: Job description of the new CDI specialist

by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS

CDI is an ever-changing and ever-evolving profession. The following is a sample job description and representation of skills required of the “new” CDI specialist; a staff member who can respond to the transformation of healthcare from volume based fee-for-service delivery to a model vested in quality, value, efficiency, and outcomes; a staff member who represents the evolution of CDI efforts beyond the realms of reimbursement.

Job description

Review of paper and electronic health records for accurate and complete documentation of all relevant diagnoses, procedures, and ancillary treatments.

Applicants must demonstrate a willingness to maintain awareness of the business of medicine and transitional healthcare changes, including but not limited to value-based purchasing, bundled payments, accountable care organizations, and the readmission reduction program.

Must be devoted to ongoing, continuous learning in clinical medicine; practical understanding of ICD-10 and ability to educate physicians on the merits of preparation as the best practice strategy for ICD-10 readiness in their office and hospital setting; relevant updates and happenings in the business of medicine directly impacting physician’s, updates from CMS carriers effecting physicians such as billing, documentation, and coding guidelines and policies.

Flexible hours required in order to facilitate face-to-face meetings with physicians in the hospital and their private practice.

Applicants should recognize that CDI is a business with the CDI specialist representing a “business within a business,” constantly striving to think outside the box with continuous quality improvement efforts to better the business while seeking greater return on investment. Measurement of return in investment is the extent to which clinical documentation:

1. accurately reflects and reports the patient’s severity of illness equating to intensity of service
2. effectively demonstrates physician clinical judgment and medical decision making in support of medical necessity
3. promotes continuity and specificity of clinical documentation throughout the record, including progress notes reflective of the “progress” of the patient
4. facilitates complete discharge summaries in promotion of post-acute care and facilitation of orderly handoff to patient’s primary care physician

Skills/requirements

• Familiarity with MS-DRGs and the Inpatient Prospective Payment System (IPPS), including new CMS guideline of key elements including clinical documentation of what constitutes an inpatient admission (see 2014 IPPS proposed rule)
• Strong clinical knowledge and demonstrated commitment to maintaining relevancy in clinical field
• Familiarity with ICD-9-CM and ICD-10-CM Official Coding Guidelines
• General knowledge of what constitutes a complete and accurate record—i.e., complete and thorough clinical documentation beginning with the emergency room reflective of clinical presentation of patient; reason for admission that clearly establishes and meets medical necessity criteria; need for continued stay in the hospital including response to treatments, interventions, and outcomes; complete and accurate discharge summary.
• Practical knowledge and understanding of official physician E & M guidelines and documentation requirements in support of proper E & M assignment and establishment of medical necessity
• Effective ability and willingness to communicate benefits of complete and accurate documentation to physicians relating to their daily practice of medicine
• Commitment to continuously increasing knowledge in and familiarity in constantly changing updates in the business of medicine directly impacting physician’s business of the practice of medicine today and in the future
• Demonstrated ability to obtain documentation relevant to denials avoidance related to the Recovery Audit program, the Comprehensive Error Rate Testing (CERT) program, and other audit programs, recognizing and promulgating to physicians the synergies of clinical documentation for both the physician and the hospital.
• Ability to review medical necessity denials and provide constructive feedback to providers
• Ability to work with all physician specialties in clinical documentation improvement initiatives, effectively tailoring learning and education opportunities to each physician specialty on an “as you go” basis.
• Ability to collaborate with case managers to collaboratively capture patient severity of illness and intensity of service to ensure medical necessity.
• Willingness to register for and attend all relevant ICD-10 and other billing/coding related educational offerings by CMS contractors, effectively sharing with physicians on a need to know basis, integrating key concepts and elements as they relate to clinical documentation improvement into daily routines and practices of CDI.
• RN and/or RHIA required; CCDS and/or CCS strongly preferred

Editor’s note: At the time of this article's original release, Krauss was Executive Director of the Foundation for Physician Documentation Integrity.