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A clinical documentation specialist, also known as a documentation improvement specialist, is responsible for ensuring that official standards of healthcare recording and documentation are upheld. The discipline is closely related to the field of medical claims billing in the sense that both fields rely on a deep knowledge of medical codes. Clinical documentation professionals use government-sponsored professional coding systems such as ICD-10-CM and CPT to report on patient records, diagnoses, the quality of their care, and any other services provided.
Daily tasks include reviewing and analyzing health documents to properly record relevant diagnoses and procedures for patients, staying abreast of federal and state regulations, keeping informed of changes in treatment modes and new procedures, and performing coding when physician documentation is vague or missing.
Apart from these essential duties, clinical documentation (CD) specialists work collaboratively with physicians and other healthcare professionals to ensure that clinical information in the medical record is accurate, coding the appropriate utilization, clinical severity, outcome or quality of the health record, as well as ensuring what is called “compliant reimbursement” of patient services.
Certified clinical documentation specialists are a class of healthcare professionals that have come into high demand. There is now an ever-growing need for the specialized, certified skill set of clinical documentation specialists. These jobs exist at all levels of healthcare. Overall, certified clinical documentation specialists are critical to the healthcare industry’s profiling, reimbursement, quality measure reporting, and quality control standards to consistently be upheld.
Check out how to join this growing career, including information about academic programs, certifications, and salary.
Clinical Documentation Specialist Degree & Career Types
There are a number of clinical documentation specialist career options. These include positions in medical centers, research facilities, private practices, university laboratories, colleges, dental offices, psychiatric offices, medical billing centers, insurance companies, and other healthcare facilities. Each of these jobs provide training to bring its clinical documentation professionals up to speed on its specific requirements.
Admissions Requirements for Clinical Documentation Programs
In terms of admissions requirements for students interested in a career in clinical documentation, criteria vary depending on whether the program is hosted by a college or by a professional association.
For example, Labouré College’s CDI (clinical documentation improvement) program requires a $25 application fee, documentation of high school graduation, GED completion (or other state approved equivalency credential), and official college transcripts, if applicable.
Diploma, certificate, and associate degree programs generally require the submission of one’s secondary school transcripts, an application fee, and proof of English proficiency for ESL students.
Clinical Documentation Program Accreditation
Students considering careers clinical documentation should pay close attention to a school’s accreditation status before applying. Accreditation ensures that a school’s standards (or those of a specific educational program) has met a set of peer-reviewed guidelines.
There are several programmatic accreditation bodies, which approve educational programs related to clinical documentation in healthcare.
The Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) offers accreditation of health information management programs. The American Health Information Management Association (AHIMA) offers accreditation as well, through its Professional Certificate Approval Program.
Although not all diploma, certificate, and degree programs for aspiring clinical documentation specialists have received recognition from one of the above bodies, students should ensure that their institution of choice at least as regional accreditation. A full list of reputable regional accreditation entities is available on the Council for Higher Education Accreditation (CHEA) website.
Clinical Documentation Postsecondary Nondegree Award Programs
This CDEO (Certified Documentation Expert – Outpatient) online clinical documentation improvement training course prepares students for entry-level work as clinical documentation specialists. The clinical documentation expert outpatient certification is targeted toward professionals with prior knowledge of medical coding or auditing, preferably at least two years. The course is taught by leading AAPC instructors and requires the textbooks and reference materials on AMA’s Current Procedural Terminology (CPT), ICD-10-CM, and the Healthcare Common Procedure Coding System (HCPCS).
- Location: Online
- Duration: Varies, Self-Directed
- Accreditation: Joint Commission for the Accreditation of Health Organizations (JCAHO)
- Tuition: $1,695 for CDEO course; $2,330 for complete CDEO Training Package
AHIMA’s clinical documentation improvement certification offers a module-based approach to certification as a CDI professional. There are no academic prerequisites and students have access to the site and its resources for one full calendar year after application and payment. There are four courses that must be completed.
- Location: Online
- Duration: One year
- Accreditation: National Commission for Certifying Agencies (NCCA)
- Tuition: Contact AHIMA for a customized assessment
The online certificate in clinical documentation improvement from Labouré College offers an innovative course of study on clinical documentation that teaches the fundamentals of documentation management, data operations, and health information technology. This is one of the only programs in the country that prepares students for both main national certification exams: CDIP (Certified Documentation Improvement Practitioner) from AHIMA and CCDS (Certified Clinical Documentation Specialist) from ACDIS (Association of Clinical Documentation Integrity Specialists).
- Location: Online
- Duration: One Year
- Accreditation: New England Commission of Higher Education
- Tuition: $375 per credit
How Long Does it Take to Become a Clinical Documentation Specialist?
The road to becoming a documentation improvement specialist varies. Expect a minimum of one year to attain a postsecondary award in a clinical documentation specialization. Allot enough time to complete programs, up to perhaps three years, as some are on predetermined schedules and others are completed at the student’s pace.
Students pursuing a bachelor’s degree in health information technology or a related field might need up to five years to complete, including certification.
How To Become a Clinical Documentation Specialist – Step-by-Step Guide
Becoming a clinical documentation specialist, as mentioned above, should take students a minimum of one year and up to five years after high school, depending on the educational path chosen, certifications needed, and clinical and industry experience required.
Step 1: Graduate from High School (Four Years)
As a high school student, a focus on classes in English and language arts, algebra, chemistry, physics, psychology, biology, geometry, speech, and anatomy/physiology can help to build a solid foundation for pursuing a certification in clinical documentation improvement.
Step 2: Earn a Postsecondary Nondegree Award or Certification (One Year or More)
Earn a certification or postsecondary nondegree award in clinical documentation (CDI) or as a documentation improvement practitioner (CDIP) to qualify yourself as a professional in the field. AHIMA’s aforementioned CDI certification is a great place to begin.
Step 3: Gain Industry Experience (At Least One Year)
One way to advance a career as a clinical documentation specialist is to gain work experience in the health and medical records industry. This helps a candidate prepare for more advanced certifications, gaining the experience necessary for more leadership responsibilities, which are typically requisite in candidates being considered for positions in upper management or as clinical directors.
Step 4: Earn an Associate or Bachelor’s Degree (Optional, One to Four Years)
Earning an associate of science or arts (AS, AS, AAS) or a bachelor of science or arts (BS, BA) in health information management or health information technology can increase one’s earnings and open doors to upper-level positions. It should be made clear that college degrees of any kind are not necessary for those interested in a clinical documentation specialist career.
What Do Clinical Documentation Specialists Do?
A clinical documentation specialist, also known as a documentation improvement specialist, is responsible for ensuring that official standards of healthcare recording and documentation are upheld. The job is closely-related to medical claims billing in the sense that both fields rely on a deep, studious recall of medical codes.
Clinical documentation jobs exist at all levels of healthcare, and as paperwork (or its digital equivalent) will never go away, certified clinical documentation specialists are critical to healthcare businesses so that their profiling, reimbursement, quality measure reporting, and quality control standards are consistently upheld.
Apart from these essential duties, CD specialists collaborate with other healthcare professionals to ensure that clinical information in the medical record is accurate, code the appropriate utilization, and ensure what is called “compliant reimbursement” of any and all patient services.
Some critical skills for clinical documentation or clinical documentation improvement practitioners include:
- Working knowledge of basic computer programs
- Working knowledge of Microsoft Office Suite
- Thorough knowledge of industry coding practices (e.g., ICD-10-CM)
- Inpatient/outpatient coding skills
- Interpersonal skills
- Communications skills
- Chart review experience
- Electronic medical record (EMR) experience
- Clinical documentation specialization/improvement software experience
- Background in reporting
Clinical Documentation Specialist Certifications & Licensure
To become a clinical documentation specialist, you can become certified through either the Association of Clinical Documentation Integrity Specialists (ACDIS), featuring certifications for entry-level employees, or the clinical documentation improvement practitioner course of study via the American Health Information Management Association (AHIMA).
AHIMA offers just the one certification, while ACDIS hosts three: the Certified Clinical Documentation Specialist (CCDS), the Certified Clinical Documentation Specialist – Outpatient (CCDS-O), and an ACDIS-Approved CDI Apprentice Program.
The qualifications and certification procedures vary at each level of credentialing and are available on their websites.
How Much Do Clinical Documentation Specialists Make?
The Bureau of Labor Statistics (BLS 2019) reports that the clinical documentation-related field of medical records and health information technicians is set to grow 11 percent between 2018 and 2028, adding 23,100 jobs. The BLS notes that the required entry-level education for a clinical documentation specialist is a postsecondary nondegree award.
Finally, here are the detailed salary data for the 215,500 medical records and health information technicians in the United States, according to the BLS (2019):
- Average annual salary: $44,387
- 10th percentile salary: $26,550
- 50th percentile (median): $40,350
- 90th percentile: $66,260
Kenneth is a feature writer, poet, and musician living in the Pacific Northwest. His writing on remote work, education, and technology has been published by BustedCubicle.com, MedicalTechnologySchools.com, and other websites. His poetry, short fiction, and album reviews have appeared in Scifaikuest, Nanoism, and No Clean Singing. His background includes time spent as an associate editor, proofreader, private grammar instructor, freelance content editor, medical claims agent, and SEO consultant. He is a graduate of the University of Oregon, where he studied literature and worked as a composition tutor.