Clinical Documentation Improvement (CDI) Specialists are trained clinical professionals who understand the clinical aspects of disease processes, illness pathogenesis, pharmacodynamics, medical and surgical procedures. CDI closes the gap between clinical criteria, validation and complexity of coding guidelines.
Coding professionals are responsible for assigning standardized codes to describe signs, symptoms, conditions, diagnoses, procedures and medical services rendered to patients. The ICD-10-CM, ICD-10-PCS and CPT4 codes assigned are used to submit claims, receive proper reimbursement, provide education, track statistics, data mining, research, and quality improvement.
Complete documentation and accurate coding practices help prevent errors while promoting compliance. Together, the collaboration between CDI specialists and coding professionals help achieve the best quality healthcare for patients. Below is a side-by-side comparison on the credentials, background, and duties of both roles.
| CDI SPECIALISTS | CODING PROFESSIONALS | |
|---|---|---|
| PROFESSIONAL ASSOCIATIONS | The Association of Clinical Documentation Integrity Specialists (ACDIS) | • The American Health Information Management Association (AHIMA) • American Academy of Professional Coders (AAPC) |
| CREDENTIALS | • Certified Clinical Documentation Specialist (CCDS) • Clinical Documentation Integrity Practitioner (CDIP) | • Registered Health Information Administrator (RHIA) • Registered Health Information Technician (RHIT) • Certified Coding Specialist (CCS) • Certified Coding Specialist Physician-Based (CCS-P) • Certified Professional Coder (CPC) • Certified Professional Coder- Payer (CPC-P) |
| BACKGROUND | Clinician background (i.e., registered nurses) | Medical coding background |
| DUTIES/TASKS | • Focuses on the clinical picture • Record review while patient’s in-house • Reviews and reports working DRG • CDI queries on clinical criteria and supporting documentation | • Focuses on code assignment • Record review after patient’s discharged • Reviews and reports final DRG • Coding queries on clinical validation and documentation clarification |
Both CDI and coding roles are essential in the healthcare industry. They play key parts in the goal of maintaining accurate and complete documentation, communicating with clinicians and promoting auditing processes and quality control to ensure accuracy and compliance.
Learn more about the Roles of CDI Specialists and Coding Professionals in our On-Demand Webinar: The Role of CDI. Learn more and/or register to watch.
