Credentials for CDI job descriptions

edited May 15 in CDI Management
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
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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

  • Thanks, Katy. This gives me a lot of food for thought. 
  • edited May 15
    cseluke said:
    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

    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. 


  • Thank you, Paul. 
  • Note the ACDIS Position paper- https://acdis.org/resources/cdi-more-credential
    well said Katy. 
  • 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. 



    Yes, the RAC Scope of Work created a lot of issues within the profession!

    Jeff

  • Thank you Katy and Paul!  Well said! In the past, I have trained many newly hired RNs and HIM professionals for the CDI specialist role.   I think the success of that person depends on many things and the background credential is just 1 of the many factors contributing to a successful CDI professional.  Cathy, I hope you are able to find a way that works to transform your program to allow HIM professionals to be considered for the CDI positions. 

    Sincerely,
    Tammy
     
  • Hi Cathy,

    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
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