Career Choice: The challenges and the rewards of becoming a CDI specialist
By Lois Mazza, CPC
In 2004, I passed the AAPC certification exam and became a certified professional coder. Since that time, I’ve worked as a coder in several different specialties. When I began my first coding assignment as a new coding graduate with no coding experience, I had only a very rudimentary knowledge of the complexities of medical coding. I possessed a solid foundation and a clear understanding of coding basics, but I was about to discover the many challenges that all coders face when choosing to pursue the coding profession.
After several years working in a variety of specialty settings, I was offered the role of documentation specialist. This particular role focused on inpatient evaluation and management professional services. While in this role, I identified encounters in which coders downcoded services due to insufficient documentation and then provided education to coders and physicians to try prevent this from happening again.
The CDI specialist role is relatively new. In the past, coders provided minimal education to physicians about documentation deficiencies. CDI was not a separate initiative, nor did it encompass employees whose sole task was devoted to the concept of improving documentation and educating providers.
These days, with the emphasis on DRGs and ICD-10-CM/PCS, organizations need dedicated CDI specialists who can educate providers about documentation specificity related to patient encounters, services, and procedures.
One challenge for some CDI specialists is that they may be part of a newly-formed department. This means that the specialist may be required to provide input into the creation of policies and procedures that don’t yet exist.
In addition, a new CDI program may not have sufficient space in the facility. Specialists may need to be flexible in terms of where they work and their working conditions. When interviewing for a CDI specialist position, ask about the CDI program itself, including:
- When it was implemented
- How well it has been received
- Whether the facility provides adequate space in which to work
Some facilities may require CDI specialists to work in the same area where the providers spend most of their time (i.e., the nursing floors). This enables face-to-face communication and discussions about documentation issues. However, it can also be distracting to work on the nursing floor. Patient care areas may be noisy and unpredictable.
CDI specialists are generally expected to educate physicians. If they discover invalid, deficient, or missing documentation, their job is to bring this to the provider’s attention and render appropriate education.
Some providers welcome correction and education and are glad to discuss their documentation issues. However, not all providers feel this way. CDI specialists must be able to communicate clearly, respectfully, and effectively when approaching these providers.
Remember that most providers haven’t studied coding or the CMS documentation guidelines. They may have an awareness of coding and documentation principals but not a thorough understanding of what’s required.
- Don’t take physician's negative attitudes toward CDI, coding (and staff) personally.
- Remember that providers are generally very busy and don’t want to receive negative feedback. Remain pleasant but firm when speaking with them. Tell them that you have an important message for them.
- Keep your lesson as brief and to the point as possible.
- Try to get the provider to set aside 10-15 minutes to speak with you. Some may not even have that amount of time to spare.
- Be ready to show examples from the provider’s specific documentation to support the point that you’re trying to make. These examples should be clearly stated. Highlight the specific documentation issue/problem in each example.
- Follow up by email with a thank you and reiteration of what you discussed.
- As with the education session itself, keep the email as brief as possible.
Some facilities may require CDI specialistts to present information to large groups of providers during medical staff meetings. This is something to consider. If you enjoy public speaking, then this would be an easy transition. However, if you have a fear of speaking publically, you may need to enhance your skills in this area. Inquire during the interview about any public speaking requirements. Overcoming your fear of public speaking is a great confidence booster.
Despite the challenges, becoming a CDI specialist can be extremely rewarding. First, salaries for CDI specialists tend to be fairly high and qualified professionals appear to be in high demand.
The CDI process is rewarding because you know that what you do directly contributes to improved documentation and reimbursement for the facility. If you are hired into a newly-created CDI program, you’ll also have the satisfaction of knowing that you’ve helped to create a robust program.
As with any transition, there are both challenges and rewards. If you are a well-experienced coder or nurse who has spent many hours reviewing provider documentation—and you’re capable of educating physicians or are willing to be trained to do so—you may want to consider pursuing the CDI profession.
Editor’s note: Mazza is a CDI specialist for a large hospital organization in eastern Massachusetts. She can be reached at lmazza888@gmail.com. This article originally published on JustCoding.com.