ON THE MOST widely used job search websites, listings for
clinical documentation improvement (CDI) specialists typically
look something like this:
Description: The clinical documentation improvement specialist
provides support of clinical documentation improvement activities
in an effort to support accuracy and quality in the patient records
at Hospital X and to ensure that coded diagnoses are an accurate
reflection of the patient’s clinical status and care.
Duties and responsibilities: Participating in education of members of the patient care team on documentation guidelines; electronically querying physicians/other providers regarding missing,
unclear, or conflicting medical record documentation.
Licensure or certifications: RHIA, RHIT, BSN, RN, MD, or comparable. The following are preferred: CDIP, CCDS, CCS, and ICD- 10
certification or designation.
There are two different types of healthcare professionals that
can look at this description and envision it as a stop on their career path—coders and nurses. The answer to the question about
just who can do this job the best, however, is at the crux of a professional rivalry that remains just under the surface on teams of
CDI specialists working all over the United States.
Some CDI teams were built around the belief that registered
nurses, both with and without CDI and coding credentials
such as the CCS or CDIP, are the best fit for the job. Other CDI
teams were assembled based on an assumption that health
information management (HIM) professionals with some
combination of coding or CDI credentials best fit the bill. But
there’s a third option that some providers—and AHIMA—
believe works best: the hybrid approach. Ideally, a hybrid CDI
team consists of both credentialed HIM professionals and registered nurses.
In practice, a hybrid team builds on the strengths of both HIM
and nurse professionals’ skillsets. A hybrid team benefits from
the knowledge of coding guidelines and compliance expertise
through its HIM professionals, as well as the intrinsic clinical
relationships that have been forged between nurses and physicians. Facilities with functioning hybrid teams have already
started to see clear financial benefits of working this way, according to several CDI experts interviewed for this article. They
also see it as an opportunity to put to rest some of the tensions
that exist between nurses and HIM professionals.
As the prominence of CDI has grown in response to reimbursement reforms and expansion into outpatient settings,
some HIM professionals remain frustrated by what they see
as resistance created by the notion that CDI requires clinical
experience that only nurses can bring. Some feel as if they are
being pushed out of CDI based on the myth that HIM professionals are insufficiently clinical. To understand why hybrid
CDI teams hold the most promise for providers, it’s important to understand the history of CDI and why tensions exist
between HIM and nursing professionals in the first place. To
overcome this rivalry, both sides need to acknowledge how
their backgrounds and skills complement each other, and why
cooperation between them can result in the best documentation possible.
CDI’s Past and Present
Over the last 10 years, with the advent of electronic health records (EHRs), clinical documentation has largely become electronic—leading to numerous changes in the way nurses, physicians, and HIM professionals do their jobs. Historically, CDI
has been a function of HIM and medical record departments.
Approximately 25 years ago, hospitals started practicing “
concurrent coding”— CDI’s precursor. Concurrent coding was performed by coding professionals who worked on hospital floors
coding charts of patients who were currently in the hospital and
querying physicians for additional details. The need for CDI
grew when diagnosis related groups (DRGs) came on the scene,
but CDI still wasn’t a priority for many providers.
In recent years, however, with the implementation of payment reforms tying reimbursement to quality-based care, CDI’s
profile began to rise. This time around, consulting companies
and CDI software vendors gained a foothold with providers
and started urging hospitals to move nurses working in areas
like quality and utilization review—which were also HIM domains—into CDI.
“The purpose of our profession [HIM] is to ensure that quality documentation supports the needs of healthcare and we’ve
been doing that all along,” says Pamela Hess, MA, RHIA, CDIP,
CCS, CPC, lead faculty, healthcare informatics at Grand Canyon
University, and vice president, strategy and operations at Me-dASTUTE Consulting.
In an effort to better understand HIM’s current reach in CDI
and to see how nurses and coders stack up in CDI roles, AHIMA recently conducted a survey that was sent to individuals in
AHIMA’s member database who identified themselves as CDI
or coding professionals, and to those who had one or more of
the following credentials: CDIP, CCDS, CCS, RN, BSN, MSN,
FNP, or MD. According to the survey, roughly 59 percent of respondents said their facilities hire HIM professionals for CDI
roles, while 41 percent do not. As for which department oversees CDI, 51 percent of respondents said their CDI teams report
to the HIM department, and roughly 18 percent of CDI reports
to the finance department. The survey also found that the most
frequently required credentials for CDI specialists were the RN
and CCS, while the most frequently preferred credentials were
the CDIP and CCDS.
When respondents were asked why they chose not to hire HIM
professionals and coders for CDI, they responded that they were
looking for staff with clinical knowledge—a curious response
given that clinical documentation has long been considered the
defining territory of HIM.
“Nurses and physicians have experience in applying clinical
knowledge in direct patient care and HIM/coding professionals
have experience in applying clinical knowledge in the accurate
representation of diagnosis and procedural codes,” the survey
report states. “Both of these areas of clinical knowledge are crucial in the accurate representation of patients through clinical
Nobody disputes that nurses and HIM professionals are quali-
Coders or Nurses for CDI
Teams: Both Work Best