Clinical Documentation Specialist Role

Dear Nurse Beth Advice Column - The following letter submitted anonymously in search for answers. Join the conversation! Nurses Nurse Beth Nursing Q/A

Specializes in Tele, ICU, Staff Development.

Dear Trying,

You asked about medical coding courses, and there are many. But let's look at your end goal to make sure it aligns with the training.

Medical Coders and Clinical Documentation Specialists

Instead of looking at training focused on becoming a Medical Coder (which does not require an RN), you are better off looking at training focused on becoming a Clinical Documentation Specialist, also known as a Clinical Documentation Improvement Specialist (which typically does require an RN).

Now, learning about medical coding will absolutely increase your knowledge and help prepare you to be a Clinical Documentation Specialist (CDIS) but being a CDIS is more than just coding.

Hospitals have always had medical coders. Medical coders extract data from a patient's medical record on the back end and translate diagnoses, procedures and treatment into billable codes.  In addition, many hospitals now also have clinical documentation improvement (CDI) programs for financial reasons. CDI teams help improve documentation in real time in order to capture the correct reimbursement. CDI Specialists require a unique skill set and it can be a rewarding and interesting speciality for the right person.

You've done some exploration in the general right direction:

  • You've already discovered AAPC, which offers the Certified Professional Coder (CPC) certification and courses, among others.
  • There's also the AHIMA which offers the  Certified Professional Code Physician-based (CCS-P).

These certifications are respected, but let me point you to the certifications most commonly listed in job postings as preferred for Clinical Documentation Improvement Specialist jobs. First, a description of the role.

Clinical Documentation Improvement Specialist

A Clinical Documentation Improvement Specialist uses your RN knowledge to concurrently and retroactively review patient charts. You confer with clinicians to improve documentation to meet ICD-10 diagnosis and medical billing code requirements. You may, for example, identify a missing billable diagnosis. This can increase revenue for the facility.

You ensure that documentation accurately reflects the patient's severity of illness and clinical treatment. Here's a couple of examples.

In your daily work, you may review the chart of a patient with heart failure and discover there's no recent ejection fraction documented, which is required for reimbursement, so you query the provider. The provider provides documentation of an ultrasound performed in the office one month ago, which meets documentation requirements. You've ensured reimbursement.

Later you may discover a third-degree pressure injury documented on a patient newly admitted through the ED to the floor. You notice that the ED documented "skin intact" but suspect the patient most likely did not develop a third-degree injury in a matter of hours but rather that the ED documentation was incorrect. In following up, you help to make sure that community-acquired pressure injuries are identified at admission so the facility does not lose reimbursement for care provided.

Some documentation requirements are not intuitive.

For example, antibiotics given to a certain population of patients must include a documented (not implied) end time as well as a documented start time. RNs may typically document just the start time. These kinds of requirements may seem picky to clinicians but can mean the difference between being fully reimbursed by Medicare or not.

Clinical Documentation Improvement Certifications

The preferred qualifications in addition to BSN are CCDS (Clinical Documentation Specialist) and CDIP (Certified Documentation Improvement Specialist) certifications.

  • The Association of Clinical Documentation Improvement Specialists (ACDIS) offers the CCDS exam 
  • AHIMA offers the CDIP exam

Certifications almost always require work experience in the speciality field. For example, a minimum of two (2) years of clinical documentation integrity experience is required to sit for the CDIP certification exam. But there are other things you can do to enhance your resume.

How to Get Started

  • Find out if there is a local ACDIS chapter in your area, and join
  • Consider ACDIS CDI apprenticeship program 
  • Learn about DRG basics and ICD-10 codes
  • Job shadow if there is a CDI program at your facility
  • Start looking at job postings to learn what is required

I hope this helps you get started, and best wishes!

Nurse Beth