I am wondering if anyone out there has any good information for me to clarify what the role of the clinical documentation improvement specialist really is. I work for a facility that has a CDI program and let me try and briefly explain what they do. They are all nurses first off. What they do is get the records and put codes on it just like the coder would. Most of the time they are all incorrect. Then it goes to the coder and they code it correctly but they are required to get the cdi's approval on their code selection even though the cdi had it wrong to begin with. The CDI never go to the floor and talk with the physicians about anything nor do they query for any documentation issues. It is always the coders catching everything. Another thing that we are told to do is we have guidelines that the coders are required to know and instead of the CDI using these clinical guidelines to consult with the provider for proper documentation we are told to just "leave off" certain things that are documented in the record. For example, if chronic respiratory failure Is documented but the patient is on less than 15 hours of oxygen therapy we are told we cannot code it. I feel that the coder should code what is documented and if those clinical guidelines are to be used they should only be used by the cdi to get clarification from the provider before it gets to the coder. I really think that my facility has somehow misconstrued the job of the cdi and I am hoping to find some info from others on how their program is done and hopefully find some info to prove this point to my employers. The cdi program is not intended for the nurses to sit in cubicles in the medical record dept and pretend code while the coder is the one really doing all the work and looking and clinical info.
Clinical documentation specialist
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