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Clinical Medical Documentation Specialist

Most people know about jobs such as medical billing and coding and even auditing. These are jobs that in high demand. However, clinical medical documentation is something that is starting to really grow in the healthcare field. There are now even certifications through the AAPC and AHIMA in clinical medical documentation if one chooses to pursue this field.

What is Clinical Medical Documentation?

According to the AAPC, “Clinical documentation improvement (CDI) is the process of reviewing medical record documentation for completeness and accuracy. CDI includes a review of disease process, diagnostic findings, and what the documentation might be missing.” (“What is clinical documentation improvement (CDI)? – AAPC,” 2021). A CDI specialist has both a background in both medical coding and in clinicals. They are responsible for bridging the gap between accurate coding and clinical documentation.

The Purpose of a Clinical Medical Documentation Improvement Program?

A CDI program is designed and implemented with the purpose of achieving accurate and thorough medical documentation. The responsibility of thorough medical record documentation is something that the provider will always be in charge of. The CDI specialist’s job is to aid the provider with their documentation. The CDI specialist is responsible for reviewing the patient’s medical record to ensure that the documentation reflects the use of the correct codes for the patient’s health status.

Impact and Benefits of a CDI Program in the Outpatient Setting

A CDI program can help to maximize revenue. When the revenue cycle is healthy, expenses and salaries can be paid with ease. When there are claim denials, that can affect the flow of revenue and that is stressful to all that are involved. A CDI specialist helps to keep these denials from happening, while also ensuring documentation is complete for clinical purposes.

The Process of Improving Clinical Documentation

Typically, a CDI specialist will review the medical record documentation after the office visit has occurred. Sometimes they are immediately after the service and other times these reviews can be performed weeks and even months after the services were performed. The provider is not queried as one might do with a question about submitting codes and claims. The CDI specialist is more of an educator to the provider, showing them the areas to improve upon to receive the maximum revenue.

This does mean the CDI specialist needs to have the best communication skills possible. For example, the CDI specialist would not suggest certain codes to be used, but would instead make the provider more aware of using specific terms and include the status of coexisting conditions that are being monitored or treated and how they affect medical decision making. These are areas that can affect coding if not worded correctly, so the job of the CDI specialist would be to help the provider to understand this.

Becoming a Clinical Documentation Specialist

The CDI will have to have coding experience. This can be a medical coder or a nurse with coding experience. Once they have this experience, they can pursue certifications through the AAPC or AHIMA. There are certifications for both inpatient and outpatient facilities and the coder can choose to become certified in one or both of them as long as they have the experience and are willing to take two certification tests.

This is a career field that is just now getting attention. So right now, it is just being implemented in most places and there are probably offices and facilities that have not even thought about implementing this program yet. However, with all of the changes in coding and the need for the best documentation possible in order to maximize revenue, there is likely to be a growing demand for CDI specialists in the future.


Written by Kara Silvers CPC, CPC-I

Kara Silvers has been in the field of medical billing and coding for 15+ years. She started out working in a small practice and has worked for a larger scale practice with 6 physicians from different specialties. She currently works from home as an instructor in Medical Billing and Coding. She is certified through the AAPC with CPC, CPB and CPC-I certifications and through the CCMA with an NHA certification.