Clinical Documentation Specialist

Many organizations now have clinical documentation improvement programs (CDIs) designed to help an organization accurately reflect the quality of patient care, illustrate healthcare services, and make precise reports of diagnosis and procedures. A clinical documentation specialist (CDS) can play a key role in the success of these programs, yet many nurses are unfamiliar with this career option. Here are answers to commonly asked questions about CDS professionals so you can determine if this role should be the next step in your career path. Even if you decide not to become a CDS, you’ll benefit from knowing what they contribute to your organization.

What is a CDS?

A CDS is a registered nurse who manages, assesses, and reviews a patient’s medical records to ensure that all the information documented reflects the patient’s severity of illness, clinical treatment, and the accuracy of documentation. Part of the role is to perform concurrent reviews of medical records, validate diagnosis codes, identify missing diagnosis, and query physicians and other healthcare providers for more specifics so documentation accurately reflects the patient’s severity of illness.

An effective CDS understands the reasons and functions of CDI programs. (See About CDI programs below.) Although the financial benefits of these programs are often emphasized, they also benefit patient care. Accurate documentation by clinicians is an important tool for managing a patient’s illness. It’s not uncommon for CDS nurses to say that every patient’s medical record is it’s own story.

Medical diagnosis and treatment produces several types of documentation, including patient records describing medical history, insurance claims and payment forms and test results from diagnostic laboratories. Clinical documentation specialists analyze this information to enable medical staff and facilities to provide better health care for patients.

About CDI programs

Many healthcare organizations embrace CDI programs for financial reasons because the programs help hospitals increase their Case Mix Index (CMI), which in turn 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. Higher CMIs result in higher reimbursement that reflects the resources used to treat the patients.

An effective CDI program also provides protection against Recovery Audit Contractors (RAC). RACs’ goal is to identify and reduce improper Medicare payments, healthcare service claims, and overpayments and underpayments to Medicare. Having accurate and specific information ensures that the patient’s documented care matches the charges.

*The DRG is an inpatient classification system that organizes patients into groups that share similar diagnosis related characteristics. This classification is based on the numerical International Classification of Disease (ICD-9), which is coded data assigned to each discharged patient during the billing cycle.

Basics

The three main tasks of clinical documentation specialists are evaluation, reporting and interpretation. These professionals need to understand medical terminology, medical procedures and applicable laws to collect and evaluate medical documentation. They prepare written reports, which they submit to decision makers, medical professionals and the public so health-care efforts in a facility can be judged objectively, sometimes by nonmedical third parties and sometimes under a deadline. And they interpret their own or others’ reports to discover positive and negative patterns and solve health-care problems.

What are some of CDS responsibilities?

Every medical record by every physician or nurse practitioner requires careful evaluation to compare the diagnosis and treatment with the actual complaint or injury of the patient admitted to the hospital.

A CDS’s typical daily workflow consists of evaluating and assessing a certain number of medical records of patients, particularly those insured by Medicare. The records are drawn from different departments, mainly intensive, cardiac care, telemetry, and medical units. When the CDS reviews the medical records, he or she looks for specificity of an illness, the accuracy of the clinician’s documentation, and documentation of important medical details. When conflicting data are found, the CDS asks the healthcare provider for more information to resolve the conflict.

Here’s an example that illustrates the importance of specificity. A physician documents congestive heart failure (CHF) in a patient’s medical record, but doesn’t specify the type and acuity. The CDS nurse asks the physician for more details because under Medicare rules there are three types of heart failure categories, each with a different reimbursement rate. The additional information allows the patient to be coded as a more complicated DRG, which translates into higher reimbursement for the hospital.

In most cases, the CDS uses a software program to create a query and place it in the medical record for the physician. If there is no answer within a day or two, the CDS contacts the physician face to face to discuss and answer the query. Often physicians are receptive, answer questions, and provide important information about the patients.

The challenge comes when physicians don’t answer queries. Unfortunately, some clinicians discard queries, seeing them as a distraction. In other cases, physicians don’t answer queries because they believe their documentation is already clear. For instance, a patient comes to the ED with chest pain, an abnormal ECG, and an elevated troponin level, and is immediately transferred to the catheterization laboratory. Although the attending physician writes “chest pain” many times in the medical record, he doesn’t specify the etiology of the chest pain because he believes it’s self-evident that the patient had a myocardial infarction (MI). The nurses know that the patient had an MI but if the physician doesn’t specify that in the progress notes, it doesn’t exist in terms of documentation, so the patient’s diagnosis can’t be coded correctly.

Records

At their most basic level, clinical documentation specialists act as medical records technicians who collect information about medical diagnoses and treatments to enter into computer databases. From it they can produce reports that health providers can analyze to determine problems or areas of improvement. In larger facilities with dedicated records technicians, documentation specialists have research, administrative and educational functions. They train health information technicians and medical staff on documentation and how to analyze health records. They track and graph statistics on disease and recovery, produce reports on the efficiency of collection methods and recommend strategies for improving processes. They often meet with health-care staff members to explain their findings.

What role does the CDS play on the team?

An effective team is important for a successful CDI program within healthcare organizations. According to the article “Documents for Success,” written by Chavis in 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…” The CDS can help bridge these language differences.

The CDS also builds strong mutual relationship with coders, who form the backbone of the CDI team. If coders don’t code accurately and concisely, on the back end of the patient’s medical record, which is the record presented to the coders after the patient is discharged from the hospital, the profile of the patient’s treatment will not accurately reflect the treatment or diagnosis that was given.

Finally, the CDS provides education to other team members. For instance, CDS nurses educate physicians on the importance of supplying the proper information needed for correct documentation. Monthly meetings with physicians and residents can be an effective education tool. At the meeting, 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.

Qualifications

Requirements for clinical documentation specialists vary by employer and job level. Entry-level positions in clinical documentation can start with an associate degree in health information technology. This course of study typically takes two years and covers such topics as medical terminology, coding systems, computer systems and health-care statistics. More advanced levels may require work experience and at least a bachelor’s degree in health services, public health or long-term care administration. The advanced education, which normally takes at least four years, includes courses in hospital organization and management, law and ethics, strategic planning and health information systems.

What is the future of the role?

The CDS role must evolve to meet an organization’s need. For example, the CDS will be an essential part of the transition to ICD-10 standards, which will become effective October 2015. The increased focus on quality as the basis for reimbursement means that organizations will add or expand CDI programs, creating opportunities for those wanting to become a CDS. Certification through the Association of Clinical Documentation Improvement Specialists is also an option for a CDS. To qualify for the Certified Clinical Documentation Specialist (CCDS) exam, applicants need 2 years of professional documentation experience. For more information on CCDS certification, visit http://www.hcpro.com/acdis/certification.cfm and for more information on the Association of Clinical Documentation Improvement Specialists, visit http://www.hcpro.com/acdis.

The CDS has the capacity to emerge as the facilitator of information necessary for the accurate completion of required documentation of clinical data, benefitting the clinical team, the organization, and most importantly, the patient.

Careers

The Bureau of Labor Statistics does not compile separate salary information for clinical documentation specialists. However, it does show information for two related professions. As of May 2011, medical records technicians earned a mean $35,920 per year, ranging from less than $21,680 to more than $55,170. This level would be equivalent to entry-level or basic specialist positions. Higher-level positions would be equal to health-services managers, whose yearly averages equaled $96,030, ranging from less than $52,730 to more than $147,890. Predicted job growth for both professions from 2010 to 2020 is greater than the average 14 percent for all jobs in all industries. For technicians, increases are expected at 16 percent; for managers, growth is projected at 22 percent.

Cristina Cassano is a nurse informatics specialist at Raritan Bay Medical Center in Perth Amboy, New Jersey.

Selected references
American Health Information Management Association (AHIMA). Guidance for clinical documentation improvement programs. Journal of AHIMA. 2010;81(5):expanded web version. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343. Accessed September 5, 2014.

Centers of Medicare & Medicaid Services (CMS). 2014. Recovery audit program. Retrieved from: www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/. Accessed September 8, 2014.

Chavis S. 2010. Document for success. Retrieved from: www.fortherecordmag.com/archives/051010p20.shtml. Accessed September 8, 2014.

Nurse Practitioner (NP) Salary

Nurse Practitioners in the United States pull down an average of $91K annually. Incomes of Nurse Practitioners vary widely depending on performance components; bonuses and profit sharing that can occasionally exceed $14K cause paychecks to spread between $74K on the low end and $121K on the high end. Compensation for this group is mainly affected by the particular firm, but geography and years of experience are influential factors as well. Roughly one in five of professionals in this line of work do not receive benefits; however, a strong majority report medical coverage and a majority claim dental coverage as well. The majority of Nurse Practitioners claim high levels of job satisfaction. Female Nurse Practitioners far outnumber their male contemporaries among survey respondents. Figures cited in this summary are based on replies to PayScale’s salary questionnaire.