The Clinical Documentation Improvement Specialist's Complete Training Guide

The Clinical Documentation Improvement Specialist's Complete Training Guide
Title The Clinical Documentation Improvement Specialist's Complete Training Guide PDF eBook
Author Laurie L. Prescott
Publisher
Pages 0
Release 2014-10-23
Genre Clinical medicine
ISBN 9781556452833

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Your new CDI specialist starts in a few weeks. They have the right background to do the job, but need orientation, training, and help understanding the core skills every new CDI needs. Don't spend time creating training materials from scratch. ACDIS' acclaimed CDI Boot Camp instructors have created The Clinical Documentation Improvement Specialist's Complete Training Guide to serve as a bridge between your new CDI specialists' first day on the job and their first effective steps reviewing records. The Clinical Documentation Improvement Specialist's Complete Training Guide is the perfect resource for CDI program managers to help new CDI professionals understand their roles and responsibilities. It will get your staff trained faster and working quicker. This training guide provides: An introduction for managers, with suggestions for training staff and guidance for manual use Sample training timelines Test-your-knowledge questions to reinforce key concepts Case study examples to illustrate essential CDI elements Documentation challenges associated with common diagnoses such as sepsis, pneumonia, and COPD Sample policies and procedures

Clinical Documentation Reference Guide - First Edition

Clinical Documentation Reference Guide - First Edition
Title Clinical Documentation Reference Guide - First Edition PDF eBook
Author AAPC
Publisher AAPC
Pages 13
Release 2020-03-12
Genre Medical
ISBN 1626889791

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It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.

Clinical Documentation Improvement for Outpatient Care

Clinical Documentation Improvement for Outpatient Care
Title Clinical Documentation Improvement for Outpatient Care PDF eBook
Author Pamela Carroll Hess
Publisher
Pages 394
Release 2018
Genre Medical history taking
ISBN 9781584265849

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Clinical Documentation Improvement for Outpatient Care: Design and Implementation is an all-inclusive guide to establishing and enhancing CDI programs for the outpatient amd professional fee setting.

Guide to Clinical Documentation

Guide to Clinical Documentation
Title Guide to Clinical Documentation PDF eBook
Author Debra Sullivan
Publisher F.A. Davis
Pages 301
Release 2011-12-22
Genre Medical
ISBN 0803629974

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Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.

Certified Documentation Improvement Practitioner (CDIP) Exam Preparation

Certified Documentation Improvement Practitioner (CDIP) Exam Preparation
Title Certified Documentation Improvement Practitioner (CDIP) Exam Preparation PDF eBook
Author Sharon Easterling
Publisher Ahima Press
Pages 139
Release 2016
Genre Medical records
ISBN 9781584264576

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Clinical Documentation Improvement (CDI) Made Easy, 2nd Edition

Clinical Documentation Improvement (CDI) Made Easy, 2nd Edition
Title Clinical Documentation Improvement (CDI) Made Easy, 2nd Edition PDF eBook
Author Anthony Nkwuaku
Publisher Createspace Independent Publishing Platform
Pages 264
Release 2018-02-24
Genre
ISBN 9781984238788

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The book provides clear guides on how to perform the vital duties required in obtaining accurate, quality, complete, and specific documentation from the providers so as to reflect the quality of care, severity of illness and risk of mortality of admitted patients during their encounter to the hospital or inpatient rehab. The book is a "must have" for every CDIS or anyone involved in clinical documentation. The book has current ICD-10-CM/PCS update with pertinent information on the 2018 Official Coding Guidelines for Coding and Reporting, Coding Clinic advice, Pay for Performance, sample queries, various disease processes by MDCs, CDI strategy for success in inpatient rehab, rehab impairment group codes and categories, list of all the surgical and MS-DRGs, and much more. Remember, if it was not documented and documented accurately, it never happened.

The Physician Advisor's Guide to Clinical Documentation Improvement

The Physician Advisor's Guide to Clinical Documentation Improvement
Title The Physician Advisor's Guide to Clinical Documentation Improvement PDF eBook
Author Trey La Charité
Publisher
Pages 0
Release 2014-04-30
Genre Diagnosis related groups
ISBN 9781615693474

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The Physician Advisor's Guide to Clinical Documentation Improvement Physician advisors are not just needed for case management anymore. ICD-10-CM/PCS and the changing landscape of healthcare reimbursement make their input invaluable in the realm of CDI and coding, too. This book will help your physician advisors quickly understand the vital role they play and how they can not only help improve healthcare reimbursement, but also reduce claims denials and improve the quality of care overall. This book will: * Provide job descriptions and sample roles and responsibilities for CDI physician advisors * Outline the importance of CDI efforts in specific relation to the needs and expectations of physicians * Highlight documentation improvement focus areas by Major Diagnostic Category * Review government initiatives and claims denial patterns, providing physician advisors concrete tools to sway physician documentation