Journal excerpt: Tips for getting started in CDI

Starting a new job can be intimidating, no matter the profession. Whether you’re coming from a clinical or coding background, the CDI role will present new challenges and come with a steep learning curve. Between coding rules and guidelines, query composition and compliance, physician engagement, keeping up with the current medical literature, and the ever-changing world of healthcare reimbursement and regulations, it’s enough to make any newbie’s head spin. So, here are some top-notch tips and ease your transition into this exciting role.

Tip 1: Collaborate with other departments in your facility

New CDI professionals need to ask for, and accept, help and education from others—both inside and outside the CDI department.

• “Work together with the coders,” says Amy S. Sterner, CCS, CCDS, CDIP, CDI specialist at Hanover Hospital in Hanover, Pennsylvania. “There is a wealth of knowledge within them, and it is not a competition.”
• “Learn to collaborate with others in your facility—coders, case managers, the quality team,” agrees Jennifer Cooper, MHIIM, RHIA, CDIP, CCS, a CDI specialist at Hunt Regional Medical Center in Greenville, Texas. “Although we have different roles, the goal is the same—quality documentation for more efficient care, regardless of the financial impact.”

Tip 2: Gather your resources

Though others at your facility are a great resource as you get comfortable with your new role, individual education can also be beneficial.

• “Use every possible minute of orientation,” says Tracy Pitts, RN, BSN, CCDS, CDI specialist at St. Luke’s Hospital in Chesterfield, Missouri. “Explore the references available in your particular program, reviewing diagnoses, associated conditions/complications, decision trees, and coding guidelines.”
•  “The first piece of advice I would offer is to join ACDIS and use the numerous resources they offer us,” says Jeff Morris, RN, BSN, CCDS, CDI supervisor at the University of South Alabama Health System. “There are also a ton of free resources available on the internet for new CDI specialists to take advantage of, including from ACDIS if you are unable to join.”
• Getting buried in books and articles trying to piece it all together could result in frustration, so if you have questions after independent reading, take them to others: your CDI manager, mentor, co-workers, or even us here at ACDIS!

Editor’s note: For more tips for getting started in CDI, read the entire article in the January/February edition of the CDI Journal. If you’re looking to enter the CDI profession, take a look at the ACDIS CDI Apprenticeship program to get you up to speed.