Credentials for CDI job descriptions
I'm looking for input on CDI job descriptions. Some background-my hospital has had a CDI program since 2001. We have always had RN's in the CDS job; in fact, the job description required an RN credential. My HR department recently revamped all our job descriptions. My HIM director (to whom I report) wants to include other credentials (e.g., RHIT, RHIA, CCS) in the job description. My all RN staff is highly offended by this suggestion. So, here I am stuck in the middle.
The main issue is really clinical validation queries. My CDI staff say that their clinical background makes them better qualified to ask clinical validation queries. I can't disagree although I certainly know that industry guidance does not prohibit coders from making clinical validation queries.
Has anyone else tackled this issue? Has anyone made separate CDS job descriptions based on credential? Let me hasten to add that I think the CDI role can be filled by coders, nurses, physicians, or really any other relevant discipline/credential. I'm really looking for advice about how to make this palatable to my staff.
Asking for a friend.
Cathy Seluke
The main issue is really clinical validation queries. My CDI staff say that their clinical background makes them better qualified to ask clinical validation queries. I can't disagree although I certainly know that industry guidance does not prohibit coders from making clinical validation queries.
Has anyone else tackled this issue? Has anyone made separate CDS job descriptions based on credential? Let me hasten to add that I think the CDI role can be filled by coders, nurses, physicians, or really any other relevant discipline/credential. I'm really looking for advice about how to make this palatable to my staff.
Asking for a friend.
Cathy Seluke
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Well, I spent 6 years trying to convince leadership to change our CDI job description to INCLUDE qualified HIM candidates, so I truly do not get the concern. I find it strange that RN's would be 'offended' that qualified HIM candidates may be considered. I fear it indicates that they don't have a full understanding of the education and training that various HIM professionals receive or the complexity of their jobs. Maybe explaining this may be helpful?
CDI is its own unique area distinct to, but drawing from, multiple disciplines (clinical, HIM, etc). Regardless of the background of the candidate, they all require education specific to the field (unless you are getting experienced candidates). The average RN requires A LOT of training to effectively perform their job well. The typical RN candidate (without prior CDI experience) does not walk in with any knowledge of coding, reportability, quality implications, etc. They also don't typically understand clinical validation either. It requires training, expanding on existing experience and clinical knowledge. Coders also have clinical knowledge (though not bedside experience) and a wealth of other experience and knowledge (coding, auditing, etc) that makes them highly valuable to a CDI team. Gaps can also be filled in for them, just like they have to be filled for RN's. In my experience, the best CDI's to not come from one background or the other, but rather, are smart, driven to learn, self-motivated, etc.
Anyone who has ran a CDI program knows that it is often difficult to find strong candidates. Casting a wider net allows consideration of more applicants and ultimately, a better team. the idea that simply because a person is an RN, that makes them more valuable than an experienced coder that may have clinical validation, auditing, or other relevant experience, is just plain incorrect and shows a lack of understanding of the complexity of CDI and respect for the coding profession. My personal feeling is that the strongest programs have both types of backgrounds as they are complementary to eachother.
As for the job description, when I eventually won my battle, we had one single job description with all potential backgrounds listed. We included, RHIT, RHIA, CCS, and RN candidates. If you have a BSN team, you could (of course) only consider candidates with a 4-yr degree...
Good Luck!
Katy
I am concerned to hear your RN staff would be offended at the suggestion that other professionals may also be deemed capable to function fully and capably within this domain.
There are some RNs within some elements of this domain, and particularly working with some consulting firms, endorse the concept that HIM professionals are not ‘as capable’ as RNs in this field. It remains a fact that I, an RHIA, CCDS, CCS, CCS-P with a proven record of success, will not be considered for employment as a CDI professional within too many institutions and some consulting firms.
I challenge the entire notion that RNs are always and universally better clinically prepared to enter this field that any/all HIM professionals. Consider that an RHIA has a B.S., and as such, is required to acquire a university education with clinical courses and exhibit and use clinical knowledge and awareness on a daily basis.
Please do not misunderstand: I am not opposed to RNs entering this field. I am opposed to the concept that HIM professionals are not well-suited for this endeavor. There are some brilliant RNs in this field, but, as in all matters of human experience, there are some RNs that are NOT intellectually equipped to succeed in this domain. In regards to clinical experience, even within the RN field, a great many RNs that are successful in this profession do not have an abundance of practical clinical experience – rather, many RNs work very capably as CDI professionals after working as Case Managers or data abstractors for decades.
I am specifically concerned that the AHIMA Publication, “Clinical Validation: the Next Level of CDI (December 2016 update)” makes the following statement:
Clinical validation is an additional process that may be performed along with DRG validation. Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record. Recovery Auditor clinicians shall review any information necessary to make a prepayment or post-payment claim determination. Clinical validation is performed by a clinician (RN, CMD or therapist). Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials.
This statement appears to have been lifted from an oft-cited oft-cited 2011 Recovery Audit Contractor (RAC) Scope of Work, which states that:
Clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials.
See RAC Scope of Work here: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/090111RACFinSOW.pdf
This statement has led some to believe that only those with a clinical credential (i.e. RN or MD/DO, etc.) can perform the work of a CDI. It is my opinion that this document pertains to RAC contractors, not CDI professionals working in other organizations.
It should be noted this statement from the RAC states that clinical validation is beyond the skills of a certified coder, leading one to ask what precisely are the skills of a certified coder? Who determines the skills and knowledge a certified coder may or may not possess? In my view, there is too much variation in terms of clinical education and awareness amongst staff working as ‘coders’. However, it is not fair to make a blanket statement that ALL coders may lack the clinical skills and education to participate fully and successfully in all aspects of the CDI function. It should be acknowledged that some ‘coders’, such as myself, have taken and passed ‘clinical’ screening exams offered by consulting firms, such as JATA and Enjoin, and that the purpose of these exams is specifically to screen for the clinical knowledge purported to be required to work successfully as a CDI professional. . It should also be noted that some RNs do not pass clinical screening exams offered by firms such as Nuance and Enjoin, and some ‘coders’ have passed the same examination.
Further, the industry needs to consider the value of ALL that have earned credentials, such as the CDIP/CCDS, that were created to demonstrate competency as a CDI professional. Do the credentials truly demonstrate competency for all?
Professionals working as a CDS should have a high level of cognitive analysis and the ability to use and integrate significant clinical acumen. It is relevant to acknowledge the educational differences between those holding the CCS, the RHIA and RHIT may be significant and may include formal college credits, anatomy and physiology, clinical pharmacology, and pathophysiology, among other areas. Regardless of background, a successful CDS requires the ability to think critically in order to compliantly use and apply clinical indicators while functioning in the CDI profession.
I posit that true ‘Clinical Validation’ requires a peer-to-peer clinical discussion – such as that which would held amongst physicians. A CDS can and should apply and use queries in a compliant manner in an effort to ensure the true clinical picture of each patient is documented and coded. A query should be posed when a condition may be documented, but additional clinical support, criteria, and or rationale is desired to ensure the documented condition is clinically supported. However, the CDI function alone does not assure true clinical validation – as is demonstrated by the fact that many clinicians working for 3rd parties repeatedly refuse to accept and honor the clinical criteria compliantly used by hospitals to ‘validate’ key clinical conditions via the existing query function. If there is some type of universal clinical language that can only be spoken and shared amongst RNs, the denial process, and the ongoing public frustration within the CDI profession with the findings issued by 3rd parties, such the RAC, speaks against any such notion.
I, and I am certain, many other HIM professionals, have issued ‘clinical validation’ queries effectively and compliantly for years. At the site (encounter) level, I believe that the background of the CDS is not material; what is relevant is that the query be written in a skillful manner and issued with proper context, clinical support and citations, and that compliant choices be offered. HIM professionals have been involved in the process of clarifying physician documentation far longer than the CDI industry has been around, and HIM professionals bring strong subject matter expertise to the table that is necessary for success.
well said Katy.
Yes, the RAC Scope of Work created a lot of issues within the profession!
Jeff
Sincerely,
Tammy
I am new to ACDIS. I am an ER nurse by profession, and I am hoping to transition to HIM particularly a CDI position. I have a Masters in Health Informatics Administration with recently passed the RHIA examination. I am still in search for a job, but to answer to your query about taking certification from an RN point of view I believed it is relevant. When I took the RHIA exam, there is a whole set of knowledge that to the most part the clinical experience truly helps, but it is equally important to understand the administrative and decision making process. For the meantime, after reading the different topics in the forum, I am incentivize to learn more and take another certification so I can have a better correlation between diagnosis and decision-making.
Melanie Green, RHIA, RN, CEN, CPEN
I would like to share some information from my perspective as an RN, CDI Analyst in Denials Dept at an Academic Medical Center. I am responsible for the Clinical Validation Denials received. I frequently see (and agree with) in the body of the actual denial what some of the previous posts stated "that clinical validation is above the scope and training of coders". Educational pathways are very specific, an HIM degree does not include A&P, pathophysiology, micro etc. to the same degree or expectations as a Registered Nurse. There are no clinical expectations with coding or HIM pathways, that is the piece that differentiates the two very different careers. Clinical support/validation is second nature for your tenured nurses, supported by solid CDI training you should have an outstanding department. In my opinion, it seems that CDI were not predominantly nurses, but coders or HIM staff. This field is very swiftly evolving and leaders should pay close attention to auditor and provider verbiage, they are also utilizing clinicians, not coders to deny for clinical validation. I believe a strong CDI Department would consist of RN's that are expected to obtain their CCDS/CDIP and coding certification like CCS or RHIT at or within specified time frames. I am certain practices like this would mitigate post discharge query rates, subsequently reducing unbilled month end numbers and denials overall, coding and clinical validation. I am fairly new to CDI but 100% top of my game as a RN, CDI and critical thinking, this is just my opinion from my own experiences. I wish you luck inevolving an awesome CDI Department.
Thank you,
DMC
Paul Evans, RHIA, CCDS, CCS, CCS-P
My response was intended to give an RN's perspective regarding CDI Dept inclusive or excusive requirements for application, not to negate any other field. The piece that coders or HIM career pathways do not receive are the clincals. That is also part of a nurses required education where more than half normally do not make it, where all of the written material is applied at the bedside. I am speaking only from my experience as a critical care nurse, CDI and now CDI Analyst. Nursing requires years of clinicals in addition to passing the required classes and NCLEX. How Anatomy & Physiology is applied with MedSurg, Critical, or Peds (many more) is the difference. Again, my intention was not to negate another's career, but I must say the career that I have chosen to follow involves much more than textbook knowledge alone. Two very different mindsets in my opinion.
Best~
DMC
Hi, Cathy,
I just want to add my two cents. Let's start from the fact that the final result of CDI work is coded data. Obviously, clinical knowledge is extremely important, however in order to make sure that your data is reported correctly your staff require to have coding expertise. I strongly believe that in order to be successful CDI team has to be blended and include both clinicians and coding professionals.
It looks like some people on this chain have a very old-fashioned view of coding professional and do not understand how comprehensive coding has become. Practically all coding programs include all the courses listed above. Seasoned coders learn a lot on their jobs, besides, a couple of years ago every organization in this country invested significant amount of resources in order to prepare coders for ICD-10 implementation.
I totally agree with Katy and Paul. CDI is an unique profession and not everyone, whether it is a nurse or a coder, is fit for it. The most important attributes for the profession are critical thinking, excellent communication skills and an ability to learn. The right person will realize fast what he or she is missing and will be able to grow with the job.
The AHIMA statement was not well thought through and definitely brought up a lot of confusion. Hopefully this can be resolved at some point as it is being questioned by a lot of people throughout the country.
I want to share my personal experience with you. Many years ago I, an HIM person, became responsible for the CDI team consisting from RNs only. I did have a previous experience working as a clinical documentation specialist in a different facility, but still the beginning was quite difficult. My boss and I were able to convince the leadership to take the blended team approach. One of the arguments that we used was this:
Both RNs and MDs are clinicians and have a similar view of the patient and similar mentality. When they discuss the patient, they understand each other perfectly, but the coder will still be confused when coding the record, so the clarifications most likely will not produce any significant results.
It happened many years ago, and I still think that making our team blended was the best decision we made, and it worked very well for our organization. Another great outcome was that working together, both coding professionals and clinicians now respect knowledge and expertise of people with different background. Our team has expanded and now also include several foreign trained MDs
Going to the beginning of your email, we have the same JD for both clinicians and coders, as the functions of the CDS are essentially the same, no matter what the background is, we just outline different requirements for credentials in the qualification section.
I wish you lots of luck in expanding your team.
Irina.
The CCDS credential is the ACDIS credential of a compentent CDI Specialist. I think many need reminding that we all have arrived at this profession in very different ways (Irina especially....but that’s a story for another time, lol) and those holding the credential should be respected equally as a CDI Specialist rather than “Coder”, “Nurse”, “foreign trained MD”, “MD”, etc... I find it hard for us to move forward as a profession when those who are highly skilled and trained constantly have to defend themselves or prove their worth. This is the type of rhetoric that has existed in the nursing world for years...it’s always been LPN vs ADN vs BSN. Now it’s BSN vs MSN vs DNP, it’s always something.
Bottom line...we all need each other and we have a great & supportive organization to assist us in growing this profession! We need to focus attention to issues in the industry and look for resolution instead of squabbling over the path that someone took to get where they are today.
Again, just my two cents...
Jeff
I think the point many of us are trying to make is that that the knowledge of 'a coder' or 'a nurse' can vary dramatically. A 'coder' with an RHIA has a very different knowledge level than a coder with a high school education who did a coding program online. Just like an LPN has a very different education than a BSN (there are LPN CDI's too). I also come from the nursing background, ER/ICU. I worked with many incredible nurses. But there were incredible ICU nurses that would have been terrible CDI's and there were many nurses I was not impressed with at all. There may be some coders without extensive patho, A&P, etc (though they do have to have some book knowledge of these subjects) but I have trained CDI nurses and found myself struggling with huge knowledge deficits in these areas as well. I have had RN's with decades of hospital nursing experience who were unable to grasp clinical criteria and never (even after years) progress a basic CDI level. It is also important to remember that there are so many areas that RN's work now (case management, UR, IT, various specialties), and this shapes their knowledge. This is why I maintain that its the person, not the degree. I think we would all agree that not every RN would be a good fit for CDI and this is true for coders as well. However, there ARE coders that are highly-effective CDI's, just as effective as RNs.
Programs can establish whatever requirements they want. There are programs that are exclusively hiring physicians (mostly foreign medical graduates), only bachelors degrees, only RN's, etc... But, when you open up you applications to more backgrounds, you can recruit additional candidates. This doesn't imply that you have to hire those applicants. It simply provides a wider pool from which to select the best applicant. it would be a shame to miss the opportunity to hire a highly qualified CDI from an HIM background in favor of an untrained RN, without the personality/skillset to succeed in this field.
Once again, I think these comments also speak to what I said in an earlier comment. I believe that those of us coming from the nursing background often don't understand the various education paths for coders. We know the difference between an LPN, ADN, BSN, APRN, PA, etc., but we may not know the difference between a CPC, CCS, RHIT, RHIA (and on and on). We may come across coders that do not appear to have extensive clinical knowledge and/or critical thinking skills. But we should be careful not to extend this to all coders. Nurses often complain about the public throwing all 'nurses' (LPN, ADN, BSN) into one bucket yet I see the same mistake being made by nurses in reference to coders.
Katy
Over the past decade, I have lead a CDI team with all others being RNs, and most of the RNs came from Case Management and the Quality Team. There are no RHIAs in my geographic region for hire; hence, none were available, nor were any RHITs.
For those of you that use Nuance, all of us, including myself, are JATA-Certified. If you believe, as do I, that the JATA screening clinical exam is difficult, the highest scores of 94 were achieved by an RN with a background of Case Management, and I also made a 94. The JATA exam is clinical, and we are told many RNs do not pass this clinical exam? I have no way of verifying this, but can only say this is what I have read from RNs from various postings?
None of the RNs on the team have ICU experience, but we are very, very effective. We know how to build queries, work with clinicians, as we cite and use clinical criteria. We have been very impactful on quality metrics, and our ROI has been 6:1. None of us start a central line, and none of us are active members of the clinical team. But, we do know how to review the CVP and MAP for relevant clinical indicators. I opine that most RNs working effectively in this domain lack ICU experience, yet they know precisely 'how' to review an ICU encounter for issues germane to CDI. None of us are an RD, yet we know how to employ ASPEN criteria, too, as another example in which a CDI may function very adequately, yet not have direct experience as a clinician. How far does one take the concept that the person working as a CDI must have direct clinical experience in order to be deemed 'competent'? Must the RN be CCU-certified in order to issue a query for CHF?
Regarding denials, I have written too many responses regarding Clinical Denials to RNs working for 3rd parties, for clinical topics such as acute MIs, and AKI, whom, for some reason, seem to cite and use definitions that are 20 years out-of-date? Reading the forum, we have ALL had this common experience?
Our CDI team uses the universal Best Practice logic and clinical awareness that any CDI team should use. Most of us hold the CCDS, as well. As we built our workflows, clinical definitions, and query forms, I did work w/ Clinicians, working to ensure our team referenced proper clinical criteria, such as KDIGO, Sepsis 2 or Sepsis 3, etc. Doing so is really second nature to me as an RHIA as I have always worked with clinical awareness and care, ensuring all codes I assign or for which I issue a query are supported. Any educated and credentialed 'coder' with experience utilizes the same coding workflow with incorporation of clinical knowledge. This is the only way to avoid justified denials.
We have one job description and HIM professionals are expected to perform the same exact work as any other CDS, and we do.
Over the years, I have had literally hundreds of ACDIS members contact me for advanced questions about the profession, and clinical criteria and knowledge is always a component of the advanced communications - these have all been my RN friends and colleagues, whom I respect greatly and with whom I am happy to collaborate, In the same fashion, I will never comprehend the vastness of this profession, and many of my RN contacts also gladly assist me if or when I call upon them. The collaboration that is most often found with ACDIS can be wonderful.
Thank you.
Paul Evans, CCDS, RHIA
This thread has definitely generated some very interesting points from a variety of perspectives and backgrounds. As a member of Cathy's all RN team, I wish to only clarify some of the emotion around this controversial topic. Our facility is indeed revamping job descriptions across the board. When the suggestion was made to open up the job description to other credentials, I must admit I was concerned. However, my concern was in no way a reflection of the highly competent HIM professionals in the CDI specialty. My concern was generated from an inherent pride in being a nurse, my educational background/clinical experience, my strong physician relationships that have been fostered over time, and concern for what the long term ramifications of this change would mean to me as a nurse in this institution. A knee-jerk reaction? Perhaps. But my reaction speaks more towards various perceptions of CDI within my own institution and HIM department rather than a belief that RHIA, CCS, etc. are not qualified to function successfully in this role. This is an internal struggle for me, and I must admit, if the previous job description did not request RN's with a preferential critical care background, I would not have applied. However, I will also admit, this is in part my own ignorance of the wealth of knowledge and expertise among my HIM colleagues.
I have worked in this role now for a little over 2 years. I have Bachelor's degrees in both biochemistry and nursing. I have worked in critical care and administration throughout my entire nursing career. I passed the JATA exam without difficulty and quickly hit the ground running. I knew nothing of coding, denials, clinical validation, etc. I have learned a great deal and continue to do so. However, my clinical background is seemingly not deemed valuable by a preponderance of my HIM peers. Relationships and communication between coders and CDI are not fostered and, in many instances, discouraged with the belief that direct communication decreases productivity. We have no idea what the backgrounds are of the inpatient coders/HIM managers, nor do they know our true value and what we all collectively bring to the table. Our inpatient coding staff tell us that clinical validation queries are outside their scope and they are uncomfortable writing them, although AHIMA states otherwise as reflected above. To open up the job description within our current facility culture, seems a bit like a double standard.
Paul, you have made some very valid points and have certainly proven yourself to be competent and more than qualified in this role. Your passion for what you do is very apparent. I have listened to your contributions via several webinars and have the utmost respect for you knowledge and efforts.
I have always believed (and have relayed to many), that we can learn something from everyone. Not all nurses are suited for this role, nor are all coders. I have worked side by side with some LPN's, MD's and respiratory therapists that I dare say were far more competent than many of the RN's I have worked with over the years. I am sure the same will be true with CDI and coders. ACDIS recognizes a variety of credentials to sit for the CCDS exam and, even though I have felt a bit devalued as a nurse in this role, I recognize the reasoning and worth of what a blended CDI department can accomplish.
So please, I think I can speak for my department as a whole in saying that our feelings are in no way generated from a belief that non-RN's can not be competent in the CDI role. Our intent was never to offend, and if that has been the case, I apologize. I think so many in healthcare have little to no understanding of what we do as CDI. This role has certainly offered me a new perspective of healthcare that I never considered before and additionally has taught me a second language; one I have yet to master. I look forward to continuing to learn and grow and contribute to this profession. We all are proud of the education and accomplishments we have made in our respective careers. No one is better than the other. How strengths are recognized, relationships fostered, perceptions made and abilities advocated will determine our overall success...respectfully, in my humble opinion.
Thank you,
Denise Worcester, BA, BSN, RN
Hi, Denise
Let me thank you for your very thoughtful response. it is regrettable to learn your HIM staff does not appreciate what you and your CDI team offer to them and that they do not appreciate your clinical background. I did not take your comments, nor those of Cathy's to mean that your department did not believe all HIM professionals are not capable of performing in the CDS role. I thank you for having the courage to address this issue. I apologize if I have offended anyone's sensibilities with my comments and passion. I echo your words that strengths need to be recognized and relationships fostered so that we may all succeed.
Sincerely, Paul
CCDS
I think any organization that discourages open dialogue and great working relationships between coding professionals and CDI's are doing the organization, and those staff, a disservice. I was thankful to have our program in HIM and work alongside our coders. I understand that productivity requirements, remote staff, etc.. can hinder those relationships.
I applaud Denise for posting to the forum and sharing her experiences.
Jeff
Denise,
I think you have provided very helpful context. I can certainly see that some of the challenges you have mentioned would potentially create some significant barriers. It is unfortunate that you feel undervalued in your role. I do not think you are alone in that experience. I think many CDS', particularly those coming from the nursing background, struggle with this. After all, this is not why we went to nursing school. I certainly identify with that sentiment.
I, like Jeff, have benefited from extremely positive relationships with coding over the course of my career in CDI. I realize much of that was luck. In my first role in CDI, I happened to be hired to start/grow our CDI program at the same time we hired a new coding manager and we were transitioning from contracted off-site coders to on-site internal staff. The coding manager and I had shared goals and worked collaboratively, even initially reviewing all death charts side-by-side for a year. Our mutual respect then extended to our teams (I believe). This and my experience with Paul and other HIM based ACDIS members (who literally taught me everything I know) really shaped how I view HIM, CDI, and what we all bring to the table so it is someone difficult for me to fully grasp some of the challenges others face in developing positive working relationships between departments.
I truly believe that so many of the problems between CDI and coding is simply lack of understanding. HIM often doesn't understand the role of CDI and vice versa. Developing these relationships in a positive way really takes a leadership effort on the part of both CDI and coding and it doesn't work when its one-sided, unfortunately. But when we talk about these very common challenges, we are typically talking about two different departments: coding and CDI. CDI is CDI. I do not mean to suggest background education is not a component. I do not mean to suggest hat we should not be proud of our background, education, and experience that came before our roles in CDI. Our education/experience may indicate specific strengths or weaknesses and will shape our work. However, regardless of prior role, the primary objective now is to perform duties as a CDI. If a person joins a CDI team, they are expected to perform ALL the duties expected of any CDI, regardless of background. I would like to believe that truly blended programs, with people from multiple backgrounds, the members of the CDI team are all seen as ONE specialty, rather than members of their respective backgrounds.
I appreciate you taking the time to respond to this forum and hope that whatever leadership decides for your department, it strengthens your department and increases everyones fulfillment.
best of luck,
Katy