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Clinical Documentation Improvement Specialist

Published
Competency-Based Apprenticeship
Sponsoring Company:
American Health Information Management Association (AHIMA)
O*Net Code
29-9021.00
Rapids Code
2026CB
Req. Hours
0
State
DC
Created
Jul 29, 2021
Updated
Jul 29, 2021

Competency-Based Skills

52 skill sets | 52 total skills
Use reference resources for code assignment
Identify principal and secondary diagnoses in order to accurately reflect the patient's hospital course
Use coding software
Assign and sequence ICD-9-CM codes
Use coding conventions
Display knowledge of payer requirements for appropriate code assignments (e.g. Content Management Systems [CMS], All Patient Refined [APR], Ambulatory Patient Groups [APG])
Assign appropriate DRG codes
Communicate with the coding/HIM staff to resolve discrepancies between the working and final DRGs
Assign Current Procedural Terminology [CPT] and/or Healthcare Common Procedure Coding Systems [HCPCS] codes
Communicate with coding/HIM staff to resolve discrepancies in documentation for CPT assignment
Promote Clinical Documentation Improvement [CDI] efforts throughout organization
Foster working relationship with CDI team members for reconciliation queries
Establish a chain of command for resolving unanswered queries
Develop documentation improvement projects
Collaborate with physician champions to promote initiatives
Establish consequences for noncompliance to queries or lack of responses to queries in collaboration with providers
Develop CDI policies and procedures
Identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of simplicity
Query providers in ethical manner to avoid potential fraud and/or compliance issues
Formulate queries to providers to clarify conflicting diagnoses
Ensure provider query response is documented in the medical record
Formulate queries to providers to clarify the clinical significance of abnormal findings identified in the record
Track responses to queries and interact with providers t obtain query responses
Interact with providers to clarify Present on Admission [POA]
Identify post-discharge query opportunities that will affect Severity of Illness [SOI], Risk of Mortality [ROM], and ultimately, case weight
Collaborate with the case management and utilization review staff to effect change in documentation
Interact with providers to clarify Hospital Acquired Conditions [HAC]
Interact with providers to clarify the documentation of core measures
Interact with providers to clarify Public Safety Indicators [PSI]
Determine facility requirements for documentation of query responses in the record to establish official policy and procedures related to CDI query activities
Develop policies regarding various stages of the query process and time frames to avoid compliance risk
Track denials and documentation practices to avoid future denials
Trend and track physician query response
Track working DRG (CDS) and coder final code
Perform quality audits of CDI content to ensure compliance with institutional policies and procedures or national guidelines
Trend and track physician query content
Trend and track physician query provider
Trend and track physician query volume
Measure the success of the CDI program through dashboard metrics
Track data for physician benchmarking and trending
Compare institution with external institutional benchmarks
Track data for CDI benchmarking and trending
Track data for specialty benchmarking and trending
Use CDI data to adjust departmental workflow
Articulate the implications of accurate coding
Educate providers and other members of the healthcare team about the importance of the documentation improvement program and the need to assign diagnoses and procedures when indicated, to their highest level of specialty
Articulate the implications of accurate coding with respect to research, public health reporting, case management and reimbursement
Monitor changes in the external regulatory environment in order to maintain compliance with all applicable agencies
Educate the appropriate staff on the clinical documentation improvement program including accurate and ethical documentation practices
Develop educational materials to facilitate documentation that supports severity of illness, risk mortality, and utilization of resources
Research and adapt successful best practices with the CDI specialty that could be utilized at one's own organization
Apply regulations pertaining to CDI activities

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