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CDI: Just Tell Me What to Say

New Credentials Emerge for CDI Specialists…Now’s Your Time to Shine

Published September 12, 2011 10:54 AM by Alice Zentner

It used to be that clinical documentation improvement (CDI) specialists were trained on the job. OJT was the only path to a CDI position. But, just like the world of coders, an evolution has occurred. Many CDI specialists now undergo formalized training. New certification testing and credentialing programs have become available, further legitimizing the need for heightened levels of documentation completeness and integrity.

  • Certified in Clinical Documentation Integrity (C-CDI) from (DocuComp)
  • Certified Clinical Documentation Specialist (CCDS) from (ACDIS - HCPro)
  • Coming this fall...AHIMA certification in CDI, Clinical Documentation Improvement Professional (CDIP)

Obtaining one of these credentials and pursuing a CDI position is an ideal career path for any health information management (HIM) professional. Jobs are plentiful and opportunities continue to expand for several reasons. Accurate and complete documentation is necessary for quality data; which in turn supports quality outcomes and reporting. Clinical documentation is the foundation for clinical coding; and will become even more important under ICD-10. New auditing and regulatory bodies rely on CDI expertise: ARRA/HITECH, audits-RAC, MAC, MIP etc-and by technology-EHRs.

The technological language of the electronic medical record and the clinical language changes needed to accurately code under ICD-10 are a major focus for CDI professionals; and will be for many years to come. Here are a few tips for existing CDI professionals and our future recruits:

  • Stay educated and be aware of what's coming up.
  • Continually incorporate regulatory changes into your CDI programs.
  • Remember to address the multiple requirements mentioned; they are interwoven into the changing healthcare paradigm.
  • Provide high level feedback on your program results to all key stakeholders.

If you decide to pursue a CDI credential, I personally welcome you to the fold. Never before has this profession been so exciting, dynamic and full of opportunity!


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