Assessment of new CDI specialists
Finding an experienced CDI specialist to fill an open position can be challenging. The art of CDI is more
than just possessing medical or coding knowledge and having the right personality; it also involves
deciphering clues in the medical record and using deductive clinical reasoning.
A CDS candidate should be comfortable initiating clinical conversations with physicians or other
providers and be able to instinctively keep the communication positive no matter the outcome. Assess
the candidate’s ability by creating imaginary uncomfortable interactions with a physician, team member,
or coder, and ask how the candidate would resolve the situation. Also, ask for an example of persuasion
to evaluate how the candidate conducts a dialogue and presents facts to avoid leading queries.
You can assess a candidate’s critical thinking skills and aptitude for concurrent review by giving the
candidate several common case studies (at least 3 or 4 are recommended). Reproduce a few anonymous
short-stay charts (blacking out any protected health information) and include emergency room
documentation, H+P, discharge summary, all labs, diagnostic imaging, consults, and nursing notes.
Using these case studies, you may wish to ask candidates to perform the following:
1. Identify the reason after study as to why the patient required inpatient treatment (principal
diagnosis)
2. Identify any comorbid conditions that were evaluated or treated (secondary diagnosis)
3. Identify any potential query opportunities:
a) Diagnoses that could potentially require clarification or lack specificity
b) Treatment, monitoring, or evaluation of a condition without a diagnosis; identification of
abnormal lab values or medications
Following are a few sample scenarios:

Example 1: An 89-year-old female is admitted through the emergency room from a nursing
home with confusion, fever, and cough. Admission diagnoses are listed as #1 fever and #2
pulmonary infiltrates with a history of congestive heart failure (CHF), dementia, and decubitus
ulcers.
o The admission assessment by nursing notes a Stage IV decubitus ulcer with consult to
the wound nurse.
o That afternoon cardiology is consulted due to increased BNP and acute CHF is
documented and treated with IV Lasix.
o On hospital day 2 the attending documents diastolic CHF improved with possible
discharge the next day.
o On hospital day 3 the patient is transferred back to the nursing home. Discharge
diagnoses are acute diastolic CHF, dementia, and fever resolved.

Example 2: A 70-year-old female arrives with shortness of breath (SOB) and is experiencing
respiratory distress after collapsing at home. The physician diagnoses the patient with syncope
and possible pneumonia. She is transferred to a medical floor with diagnoses of #1 SOB
(respiratory distress), #2 syncope, and #3 pneumonia.
o
o
o
Four hours later the patient’s breathing is worsening. Blood gases are drawn, and the
decision is made to transfer her to the ICU for respiratory support. Progress notes list
severe respiratory distress, pneumonia, and syncope. That afternoon in the ICU, the
patient worsens, and documentation of possible aspiration pneumonia occurring during
syncope is noted in the critical care note.
The patient improves and two days later is on a medical floor. A swallow evaluation is
done and the patient is placed on thickened liquids. Antibiotics continue for pneumonia
and the patient’s respiratory distress is resolved.
On hospital day 4 the patient is transferred to medical rehab. Discharge diagnoses are
#1 pneumonia and #2 syncope.
Evaluating the CDS
When evaluating potential CDS candidates using the two scenarios above, consider their ability to
perform the following during documentation review:
Example 1
The potential query is for physician documentation of decubitus ulcer (the physician only mentioned a
history of decubitus ulcers). Important information for the hiring manager is whether the nurse’s notes
are read and how the query is composed (non-leading and references current documentation).
Example 2
The potential query is to clarify respiratory “distress” with the clinical information of vital signs, blood
gases, and BiPAP in the ICU. The hiring manager should also see whether the CDS candidate considers a
query for type of pneumonia with reference to documented “possible aspiration pneumonia,” rightsided pneumonia on chest x-ray, recommendations from the swallow evaluation results, and the
changing of antibiotics.
Recommended process
The following is a recommended process for integrating the above case studies into the interview
process:

Conduct the regular interview first

At the end of the interview, provide the candidate with the scenarios in written format

Provide several scenarios involving various specialties pertinent to the organization

Provide the candidate with an area to review the information and give him or her adequate time
to perform the task

Require the candidate to complete the answers while in the interview location

Ask top-performing candidates to return for a peer interview
Evaluating performance
When evaluating a candidate’s performance, keep the following in mind:

There are no right or wrong answers. Rather, evaluate the candidate’s thought process given
the case and the clinical clues provided. You can typically tell whether a person has the aptitude
and talent for being a CDS by the answers he or she provides.

Pay close attention to the candidate’s answers to interview and scenario questions. Note that
a new candidate without CDI experience will likely have no knowledge of leading vs. non-leading
queries, so you should instead evaluate these candidates based on identifying documentation in
need of further specificity. A candidate should already have a solid baseline of clinical
knowledge, but what is more important is whether he or she can investigate beyond what is
written in the health record.

Ensure the candidate is comfortable with the autonomy of the CDI role. Many applicants come
from floor nursing, so CDI can be a drastic change.

Determine the candidate’s ability to interact with busy physicians. Ask how the candidate
would approach a physician with a query, and how he or she would react to a provider who
responds unfavorably.