The Clinical Documentation Improvement Specialist (CDIS)

 RAC Book front coverThe following is an excerpt from The RACToolkit for Hospitals and Health Systems by Elizabeth Lamkin and Amanda Berglund.  Published by HC Pro, Inc.  Copyright (c) 2011 Elizabeth Lamkin and Amanda Berglund.  Available at Amazon.

from Chapter 4: Clinical Documentation Improvement Specialist

While the ACM and PA are typically in the same line of authority, the CDIS may be located in the HIMS department and works collaboratively with the CM team, including the PA and ACM. The CDIS serves as both a resource for providers in care coordination and a concurrent documentation auditor. By using a CDIS, the quality of patient care can be monitored and both documentation and coding can be improved.

The CDIS reviews chart documentation concurrently and is well-versed in payer requirements, coding, disease processes, and compliance. As with the ACM and PA, it is essential the CDIS have good relationships with physicians. The CDIS role is different from a care manager or social worker in that the CDIS interacts with physicians, caregivers, and clinicians, not with the patients and families. Even though most organizations prefer an RN in this role, other disciplines can be trained. If the CDIS is nonclinical, the physicians may push back on their involvement in the cases. If this happens, the executive team, PA, and physician relations personnel may need to get involved to encourage collaboration on everyone’s part.

The American Health Information Management Association (AHIMA) has developed a code of ethics for CDIS staff. Ethics is an important issue as the CDIS must ensure accurate documentation that captures the severity of illness and ensures queries are performed in a compliant manner.1 There is also a certification process and association for CDIS through HCPro.2 When training the CDIS, consider having some sign-off process for a CDIS code of ethics and requiring certification within some time frame of starting.

Just as the PA reviews denial and bill hold reports in an effort to improve documentation, the CDIS should get a weekly report from the HIMS department with the number of charts that require a query. An effective CDIS should see a reduction of the number of chart queries because the discussions with the physicians are a form of education. Over time, the PA and CDIS should show a significant reduction in queries needed for accurate coding in the HIMS department.

The CDIS ensures that clinical documentation supports reporting diagnosis and procedure codes so the organization receives the optimal payment to which the facility is legally entitled. If the documentation does not support all assigned diagnosis and procedural codes, the CDIS queries the physician and, when needed, calls on the PA for advice and assistance.

The CDIS serves an important role in patient safety and quality because he or she serves as a single point of review for the entire MR and considers documentation from several sources—dietary, rehabilitation, emergency transport, etc.—not just documentation by the physician. The CDIS affects quality of care by reviewing the chart for coordination of care between all parties. There is an interesting article on the CDIS role as it affects patient safety (termed CDS in the article) on the Patient Safety and Quality Healthcare website at www.psqh.com. Search for CDS to find a link to the September 2010 article.3

Another major role of the CDIS is coordination and communication among caregivers, especially in discussing parts of the MR not created by the physician or by clinical personnel in the unit. We have often heard from physicians that the EMR is more difficult to maneuver than a paper chart when reviewing multidisciplinary notes and that it is very difficult for the physician to review all aspects of the patient’s care. The CDIS can assist physicians in providing quality and save time for the physician by accessing the records in the EMR or chart and tagging so the physician can review records in their entirety. The CDIS can provide follow-up and information to the physician about other caregiver documentation on the chart, which may have been missed or incomplete but that is pertinent to the patient’s care. The role requires expertise in maneuvering in an MR whether electronic or paper.

The CDIS position is especially vital to the RAC vulnerability issues that target MS-DRG validation, unit billing, and documentation from nursing and ancillary departments. While the ACM is focused on admission criteria, the CDIS is looking for continued documentation that supports billing to ensure the codes, charges, and documentation match. For example, the CDIS may review unit dose or therapy unit charges and compare them to CMS requirements or RAC-approved issues. If errors are found, the CDIS will notify the department responsible and discuss the issues with the clinician. Just like the ACM and PA, the CDIS is another point of education for providers and staff. In educating physicians on the CDIS role, it is important to emphasize that coordination of care results in better quality and safety for patients.

Although the CDIS is focused on appropriate documentation, the CDIS is not responsible for charge capture reviews. In Chapter 5, under clinical department directors, we will discuss charge capture and the recommendation for certain departments to implement a charge capture review by staff within the department who are familiar with the services and trained in chargemaster and billing codes.

Charge capture errors are typically underpayments due to charging omissions or coding errors, which cost the facility in lost revenue to which they are legally entitled.

Committee Participation
The CDIS concurrent audits should be documented, tracked, and reported to various committees including HIMS, the chart audit committee, UMC, and the revenue cycle department.

Footnotes
1: Information on the AHIMA Code of Ethics and a link to the detailed code documentation can be found at www.ahima.org/about/ethicscode.aspx.
2: For more information, go to the ACDIS website: www.hcpro.com/acdis/.
3: Source: Weygandt, P. (2010). The clinical documentation specialist: A key member of quality and patient safety teams. Retrieved March 3, 2011, from www.psqh.com/online-articles/231-the-clinical-documentation-specialist-a-key-member-of-quality-and-patient-safety-teams.html.