Clinical Documentation Integrity Specialist (CDIS)

woman sits on floor with computer in lap

A clinical documentation integrity (CDI) specialist uses their nursing skills to ensure that medical records provide an accurate and complete account of a patient’s health journey. 

While this position initially evolved to ensure that medical records included the correct diagnosis codes for reimbursement, it also plays an essential role in patient safety. As medical teams grow and a patient’s health status changes, a correct and accurate medical record ensures that the patient care team has all the information they need to provide high-quality care.

This article will explore the CDI nurse role, including:

  • What does a CDI nurse do?
  • Where do CDI nurses work?
  • A day in the life as a CDI nurse
  • Background and experience for CDI nurses
  • CDI specialist certifications
  • Interview tips for CDI specialists
  • Salary ranges for CDI nurses
  • Pros and cons of working as a CDI specialist
“The point of CDI is quality. We ensure that a patient’s chart is accurate and tells the right story.”

What does a CDI nurse do?

A CDI specialist uses expert nursing knowledge to review patient records for supporting evidence of diagnosis codes, diagnostic tests, and treatments. This field may also be known as clinical documentation improvement or clinical documentation nursing.

According to the Association of Clinical Documentation Integrity Specialists (ACDIS), a CDI specialist (or CDI nurse):

  • Applies their clinical knowledge to evaluate how provider documentation, lab results, diagnostic information, and treatment plans translate into coded data
  • Communicates with providers and other members of the healthcare team to clarify information or provide additional documentation when needed
  • Educates providers about good documentation practices, including how to document correct disease processes and disease severity, complexity, and acuity with an eye towards accurate medical coding
  • Utilizes clinical knowledge to report on the impact of complications, comorbidities, illness severity, mortality, case mix, and various procedures on the billed record

Here’s what the job might look like in practice: a physician may diagnose a patient with a condition like heart failure. 

The CDI then reviews the medical record to ensure that patient assessment documentation includes details that support this diagnosis, like shortness of breath upon exertion, fatigue, lower extremity edema, or irregular heartbeat. The CDI pays particular attention to evidence that laboratory testing, diagnostic procedures or imaging, and prescribed treatments match the diagnosis.

The CDI may sometimes find gaps between the provider’s diagnosis and the medical code used for reimbursement purposes. Accurate medical coding is necessary to understand how sick patients are, what resources and supplies are needed in the facility, and how insurance will reimburse the facility.

If the CDI identifies missing or potentially inaccurate information, they send a query to the provider for clarification. 

The CDI specialist also helps educate providers about how to document more specifically or accurately.

Who hires them?

CDI nurses typically work for hospital systems, although there are emerging opportunities with insurance companies.

Each employer will set specific metrics and goals for their CDI team.

For example, a CDI specialist within a hospital system may review a set of patient records that meets specific criteria. For example, they may review all records for patients admitted to a hospital unit for longer than 48 hours who are also on Medicare.

A day in the life as a remote CDI nurse

CDI nurses can work both on-site or remotely. The day begins by opening specialized software for reviewing records and the hospital’s charting system. 

Next, the CDI specialist reviews each chart in their queue to ensure that diagnosis codes align with assessment documentation, including physical exams, lab work, and diagnostic testing.

If there is a gap or question, the CDI nurse sends a query to the provider for more information. In order to recognize potential issues with a chart, the CDI nurse should have a strong background in clinical nursing, including assessment skills. 

Queries to providers can be conducted directly in the chart, over the phone, or in person. While the CDI nurse usually works independently, they must have strong interpersonal skills to develop relationships with providers to obtain the information they need for accurate charting. 

In addition to chart reviews and query follow-ups, the CDI must also attend occasional meetings and training. They can also work closely with case management to better understand a patient’s health status and treatment plan.

Background and experience for CDI nurses

While many CDI specialists may start their careers without prior experience in clinical documentation integrity, there are a number of skills that are useful in this career, including:

  • A solid understanding of anatomy and physiology, pathophysiology, and pharmacology
  • Familiarity (or willingness to learn) medical coding guidelines and private payer regulations
  • The ability to analyze and interpret medical records and appropriately query physicians about potential gaps
  • An eye for data analyzation and performance metrics

Nurses with a background in critical care or ER nursing are well-qualified for this role, but there are also specialty CDI opportunities for many different fields, including outpatient, pediatric, NICU, cardiovascular, and many more.

CDI certifications

The Association of Clinical Documentation Integrity Specialists (ACDIS) provides a number of certification options for CDI nurses.

  • Certified Clinical Documentation Specialist (CCDS): This certification requires two years of experience as a CDI specialist and a degree as an RN, RHIT, MD, or DO. Individuals with Associate’s degrees in allied health may also apply for the exam with three years of experience and relevant college-level coursework.
  • Certified Clinical Documentation Specialist-Outpatient (CCDS-O): This certification is similar to the CCDS but targets CDIs with two years of experience in an outpatient setting, including physician practices, outpatient surgical centers, hospital clinics, and the emergency department.

ACDIS also offers the CDI Apprenticeship and CDI Outpatient Apprenticeship programs for individuals who wish to enter these specialties. The apprenticeship includes educational modules about CDI basics, networking opportunities, and career support.

Interview tips for CDI nurses

Nurses who are interested in moving to CDI might benefit from familiarizing themselves with relevant software, electronic records programs, and medical coding nuances, including:

In addition, nurses should highlight their bedside experience and critical thinking skills. Preparation for CDI interviews should include potential case study examples and behavioral interview questions.

CDI Nurse salary ranges

Salary for CDI specialists ranges between $64,652 and $93,154 per year, with an average salary of $78,373, according to Salary.com.

Actual salary will depend on location, experience, and certifications. The ACDIS conducts an annual salary survey and reports that most CDI specialists in management or director positions earn over $100,000 annually. 

Pros and cons of working as a CDI Nurse

CDI is a great field for nurses looking for alternatives to bedside nurses. It is a good fit for nurses who enjoy critically analyzing patient records and putting together puzzle pieces.

This is also a great job for nurses who are more introverted. While case management requires frequent patient and team interactions, CDI nurses spend more time immersed in patient records. Physician queries may also be conducted via text or other remote communication software.

Other potential benefits include:

  • Set schedule during regular business hours
  • Potential to work in a hybrid or even fully-remote setting
  • Opportunity for deep critical thinking and analysis
  • Insight into medical coding intricacies

CDI isn’t for everyone, though. There can be challenges when it comes to obtaining necessary information from providers. At times, providers may resist responding to queries due to time demands or lack of understanding about the importance of this role. The CDI nurse must manage these relationships while helping providers understand how accurate coding supports quality patient care.

While the autonomy of remote CDI nursing can be wonderful for many nurses, it can also be isolating. Some CDI nurses mention that because the position is usually very hands-off, it can require discipline to stay on task and meet daily metric requirements.

“As the care team expands, grows, and changes, the patient chart is the common thread that ties everyone together.”

Is clinical data integrity right for you?

CDI nursing is a growing field with many opportunities for nurses looking for opportunities away from the bedside. This career offers the opportunity to support patient safety and appropriate healthcare resource allocation based on accurate, reliable patient documentation.

The profession also offers growth opportunities, from CDI Specialist to CDI Team Manager to CDI Program Director. Many CDI nurses with experience and additional certifications make healthy salaries while working remotely or in a hybrid schedule.

If you are the type of nurse who loves solving clinical puzzles and would prefer the sort of career that allows you to work from home without being on the phone for hours, then CDI nursing might be right for you.

Check out the Nurse Fern job board for CDI opportunities. Need to spruce up your resume first? The Nurse Fern resume templates can help your resume stand out. Combined with a stellar LinkedIn profile, you’ll be confidently applying in no time.

It's Here!

A 10 module course with step-by-step videos to optimize your LinkedIn profile & land your dream remote nursing role.