What Is The CDI Process?

What is the role of a clinical documentation specialist?

A clinical documentation specialist (CDS) organizes the information for each patient seen by a medical establishment.

A CDS handles this by reviewing medical records, ensuring medical codes have been inputted correctly, and documenting the specifics necessary to provide a full analysis of a patient’s health..

How do I get CDI certified?

Eligibility RequirementsHold an associate’s degree or higher, have three (3) years of experience in CDI, and have completed coursework in Medical Terminology and Anatomy and Physiology; or.Hold an CCS®, CCS-P®, RHIT®, RHIA®, RN, MD, or DO and have two years of experience in CDI.

What is a CDI query?

What are CDI queries? Clinical documentation specialists (CDS) send CDI queries to: Clarify diagnoses. … Document a diagnoses based on clinical indicators. Determine “present on admission” (POA) assignment.

What is CDI in coding?

CDI (Clinical Documentation Improvement) has been described as the process of improving healthcare records to ensure improved patient outcomes, data quality, and accurate reimbursement. … The overall goal of a CDI program is to improve clinical documentation, coding, and reimbursement.

What is the role of CDI in claims processing quizlet?

What is the role of CDI in claims processing? CDI works with coding to ensure that physician/clinician documentation is timely, complete, specific. … The physician will contact the patient to receive the remaining copay or deductible. The provider will also need to assess if the claim can be resubmitted.

How do you become a documentation specialist?

Documentation Specialist Requirements:Degree in Communications or related field.Proficiency with scanning and administrative technology.Physical strength and stamina for heavy lifting.Outstanding organizational skills.Multitasking ability.Attention to detail.Excellent written and verbal communication.More items…•

How much do CDI nurses make?

National Average As of Dec 25, 2020, the average annual pay for a CDI RN in the United States is $81,296 a year. Just in case you need a simple salary calculator, that works out to be approximately $39.08 an hour. This is the equivalent of $1,563/week or $6,775/month.

Why is clinical documentation important?

The importance of clinical documentation It captures patient care from admission to discharge, including diagnoses, treatment and resources used during their care. When the documentation is complete, detailed, and accurate, it prevents ambiguity, and improves communication between healthcare providers.

What is a CDI in healthcare?

Clinical documentation improvement (CDI) helps ensure that the events of the patient encounter are captured accurately and the electronic health record properly reflects the services that were provided.

What is the role of CDI?

Successful clinical documentation integrity (CDI) programs facilitate the accurate representation of a patient’s clinical status that translates into coded data.

What does a successful CDI program require?

Successful CDI leaders typically have either nursing, pharmacy or health information management experience, possess working knowledge of state, federal and payer-specific requirements for coding, documentation and reporting and are CDI certified through the American Health Information Management Association.

How much do clinical documentation specialists make?

National Average As of Dec 26, 2020, the average annual pay for a Clinical Documentation Specialist in the United States is $76,299 a year. Just in case you need a simple salary calculator, that works out to be approximately $36.68 an hour.

What is the primary use of clinical documentation?

The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication. The primary purpose of clinical documentation is to facilitate excellent care for patients.