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The rewarding role of 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.

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.

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.

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.

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.

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.

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