June 30, 2013
Response by Cristina Cassano, to the topic “The New Millennium: Evolving and Emerging Roles” (May 31, 2012)
I write in response to the OJIN topic “The New Millennium: Evolving and Emerging Roles” and to provide information about clinical documentation improvement programs and their impact on healthcare organizations, especially a new position arising from these initiatives, the clinical documentation specialist. Clinical documentation improvement programs (CDIs) have been adopted in many organizations to properly reflect the quality of patient care and accurately illustrate healthcare services (AHIMA, 2010). A clinical documentation specialist (CDS) is a professional registered nurse that reviews patients’ medical records to ensure that all information is accurately documented and reflects a patient’s severity of illness.
These programs help hospitals to increase their Case Mix Index (CMI) which results in higher revenue. CMI is the average of the diagnosis related group (DRG) weights for a group of patients, indicating the severity or weight of a patient population (AHIMA, 2010). The DRG is an inpatient classification system that organizes patients into groups that share similar diagnosis related characteristics.
The position clinical documentation specialist assumes that every chart by every physician requires careful evaluation in order to compare the diagnosis and treatment with the actual complaint or injury of the patient. When conflicting data are found, physicians need to be queried to rectify the lack of information provided. If the physician documents Congested Heart Failure (CHF) and does not specify the type and acuity, then the CDS nurse needs to query the physician for specificity because the Medicare rules under the DRG system requires clarification. The condition must be specified for the organization to be reimbursed properly. The query process is necessary, and physicians need to respond. If the physician does not answer after a day or two, nurses will communicate with the physician face to face. Many times physicians are very receptive, giving CDSs important information about the patients. The challenge comes when physicians do not answer their queries.For a CDI program to be successful, CDS nurses must help educate physicians about supplying the proper information needed for correct documentation. Monthly meetings with physicians and residents can be an effective education tool where the CDS can stress the importance of linking the etiology with the diagnosis and illustrate how different diagnoses will be given different relative weights for DRGs.
According to Chavis (2010), "Clinical documentation improvement clearly depends on documenting in the language of coding, which isn't always exactly how nurses or physicians are trained and think..." (p. 20). Coders are experts in coding and they are the backbone of the hospital's reports; if they do not code accurately, the hospital’s profile may not reflect the most accurate picture. CDSs review charts concurrently to provide concise, accurate documentation on all diagnoses and not just the ones that affect the DRGs.
The role of the clinical documentation specialist must further evolve to meet the organizations’ expanding demands. With the ICD-10 coming into practice, the CDI is going to become more involved. CDSs will then need to understand and adapt to the transition to the international coding standards. Pursuing a career as a CDI nurse requires either on the job training or prior coding experience, while additional training is available through courses both on or offline. More information can be found at the AHIMA (2013) and Education Portal (2003-2013) websites.
Cristina Cassano, MSN, RN, CDS
American Health Information Management Association (AHIMA). (2010). Guidance for clinical documentation improvement programs. Journal of AHIMA, 81(5). Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343
American Health Information Management Association. (2010). Clinical documentation improvement program. Retrieved from www.ahima.org/ContinuingEd/Campus/courseinfo/cdi.aspx
Chavis, S. (2010). Document for success. Retrieved from www.fortherecordmag.com/archives/051010p20.shtml
Education Portal. (2003-2013). How to become a clinical documentation specialist. Retrieved from http://education-portal.com/articles/How_to_Become_a_Clinical_Documentation_Specialist.html