Clinical Documentation Specialist Education

  clinical documentation specialist education: The Clinical Documentation Improvement Specialist's Complete Training Guide Laurie L. Prescott, 2014-10-23 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 specialist education: The CCDS Exam Study Guide , 2010
  clinical documentation specialist education: Certified Documentation Improvement Practitioner (CDIP) Exam Preparation Sharon Easterling, 2016
  clinical documentation specialist education: The Book of Style for Medical Transcription Lea M. Sims, 2008-06
  clinical documentation specialist education: Empowering Learners American Association of School Librarians, 2013-01-01 Empowering Learners advances school library programs to meet the needs of the changing school library environment and is guided by the Standards for the 21st-Century Learner and Standards for the 21st-Century Learner in Action.
  clinical documentation specialist education: 2022 CDI Pocket Guide Pinson & Tang LLC, 2021-10-15
  clinical documentation specialist education: DRG Expert Ingenix, 2010-09 THE DRG EXPERT has been a trusted and comprehensive reference to the DRG classification system for over 25 years. Organized by major diagnostic category (MDC), the convenient and innovative book layout follows the logical MS-DRG decision process. This is a must-have reference for those who need to verify DRG information and accurately assign MS-DRGs concurrently or retrospectively.
  clinical documentation specialist education: Clinical Documentation Reference Guide - First Edition AAPC, 2020-03-12 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 specialist education: The Complete Guide to CDI Management Cheryl Ericson, Stephanie Hawley, RN, Bsn, ACM, Anny Pang Yuen, 2016-01-28 The Complete Guide to CDI Management Cheryl Ericson, MS, RN, CCDS, CDIP Stephanie Hawley, RN, BSN, ACM Anny Pang Yuen, RHIA, CCS, CCDS, CDIP Managing a CDI department can be a daunting task for new and seasoned managers alike. The Complete Guide to CDIManagement provides CDI program managers and directors with insight into the most common issues associated with implementing, staffing, running, and growing a CDI department. The book also covers core skills such as auditing and metrics, and it provides strategies for overcoming challenges related to electronic records, changing regulatory landscapes, and resource limitations. The Complete Guide to CDI Management incorporates the deep expertise of multiple authors with varied backgrounds who have come together to share their firsthand knowledge. From reporting structures and productivity measurement to defining a mission and physician engagement, this definitive resource addresses the wide array of issues facing CDI managers and directors in today's hospital environment. Table of Contents About the Authors Introduction Chapter 1: An Introduction to CDI for the New Manager History of Coded Data The Medical Coder The Prospective Payment System Adding Severity Into the DRG Methodology CDI Basics Summary Chapter 2: Growing a CDI Department The Traditional Role of CDI CDI Review Population Principal Diagnosis Assignment Types of DRG Reviews Quality Focus Summary Chapter 3: Developing Relationships Sharing the Mission Physician Engagement Obstacles to Developing a Physician Relationship Leveraging Queries as an Educational Tool The Art of Clinical Validation The Query Format Query Templates Fostering a Relationship With Coding Networking Summary Chapter 4: Department Structures and Staffing Expectations Department Structures Staffing/Hiring Physician Advisor Creating a Career Ladder Continuing Education CDI Department Meetings Evaluations Credentialing Initialing vs. Revitalizing Summary Chapter 5: Demonstrating the Return on Investment Measuring Success Productivity and Sample Metrics Summary Chapter 6: Challenges and How to Overcome Them Organization Issues Resource Issues Summary Appendixes Appendix A: Resources
  clinical documentation specialist education: Guide to Clinical Documentation Debra Sullivan, 2011-12-22 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.
  clinical documentation specialist education: First Steps in Outpatient CDI Anny Pang Yuen, Page Knauss, 2017-06-22 First Steps in Outpatient CDI: Tips and Tools for Building a Program Anny P. Yuen, RHIA, CCS, CCDS, CDIP Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO Find best practices and helpful advice for getting started in outpatient CDI with First Steps in Outpatient CDI: Tips and Tools for Building a Program. This first-of-its-kind book provides an overview of what outpatient CDI entails, covers industry guidance and standards for outpatient documentation, reviews the duties of outpatient CDI specialists, and examines how to obtain backing from leadership. Accurate documentation is important not just for code assignment, but also for a variety of quality and reimbursement concerns. In the past decade, outpatient visits increased by 44% while hospital visits decreased by nearly 20%, according to the Medicare Payment Advisory Commission. However, just because physicians are outside the hospital walls doesn't mean they're free from documentation challenges. For these reasons, CDI programs are offering their assistance to physician practices, ambulatory surgical centers, and even emergency rooms. This book will explore those opportunities and take a look at how others are expanding their record review efforts in the outpatient world. This book will help you: Target the outpatient settings that offer the greatest CDI opportunities Understand the quality and payment initiatives affecting outpatient services Understand the coding differences between inpatient and outpatient settings Identify data targets Incorporate physician needs to ensure support for program expansion Assess needs by program type
  clinical documentation specialist education: The Physician Advisor's Guide to Clinical Documentation Improvement Trey La Charité, James S Kennedy, MD, CCS, Cdip, 2014-04-30 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
  clinical documentation specialist education: Health Professions Education Institute of Medicine, Board on Health Care Services, Committee on the Health Professions Education Summit, 2003-07-01 The Institute of Medicine study Crossing the Quality Chasm (2001) recommended that an interdisciplinary summit be held to further reform of health professions education in order to enhance quality and patient safety. Health Professions Education: A Bridge to Quality is the follow up to that summit, held in June 2002, where 150 participants across disciplines and occupations developed ideas about how to integrate a core set of competencies into health professions education. These core competencies include patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, and informatics. This book recommends a mix of approaches to health education improvement, including those related to oversight processes, the training environment, research, public reporting, and leadership. Educators, administrators, and health professionals can use this book to help achieve an approach to education that better prepares clinicians to meet both the needs of patients and the requirements of a changing health care system.
  clinical documentation specialist education: Nursing2022 Drug Handbook Lippincott Williams & Wilkins, 2021-03-04 THE #1 Drug Guide for nurses & other clinicians...always dependable, always up to date! Look for these outstanding features: Completely updated nursing-focused drug monographs featuring 3,500 generic, brand-name, and combination drugs in an easy A-to-Z format NEW 32 brand-new FDA-approved drugs in this edition, including the COVID-19 drug remdesivir—tabbed and conveniently grouped in a handy “NEW DRUGS” section for easy retrieval NEW Thousands of clinical updates—new dosages and indications, Black Box warnings, genetic-related information, adverse reactions, nursing considerations, clinical alerts, and patient teaching information Special focus on U.S. and Canadian drug safety issues and concerns Photoguide insert with images of 439 commonly prescribed tablets and capsules
  clinical documentation specialist education: The Physician Advisor's Guide to Clinical Documentation Integrity, Second Edition Trey La Charité, 2020-08 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.
  clinical documentation specialist education: Acdis Answers , 2016-12-16 ACDIS Answers: Clinical Documentation Improvement FAQs ACDIS Answers: Clinical Documentation Improvement FAQs is a quick reference guide for the most common questions faced by CDI specialists. Organized by Major Diagnostic Categories and broken down into specific topics of concern, ACDIS Answers provides information not only on documentation needs but also on issues related to the CDI profession. This compendium of commonly asked CDI questions is an essential reference book and office companion, valuable for new CDI specialists as well as those experienced in concurrent medical record review. Whether you're wondering about sequencing guidelines, staff productivity, escalation policies, diabetes coding, or documentation requirements for acute kidney injury, ACDIS Answers provides quick, easily understandable information from respected experts in CDI, including ACDIS' own Boot Camp instructors and Advisory Board members.
  clinical documentation specialist education: Registered Health Information Administrator (RHIA) Patricia Shaw, Darcy Carter, Heather Merkley, 2010-01-01
  clinical documentation specialist education: 2021 CDI Pocket Guide Cynthia Tang, Richard Pinson, 2020-10-15
  clinical documentation specialist education: The Clinical Documentation Improvement Specialist's Handbook, Second Edition Heather Taillon, 2011-01-21 The Clinical Documentation Improvement Specialist's Handbook, Second Edition Marion Kruse, MBA, RN; Heather Taillon, RHIA, CCDS Get the guidance you need to make your CDI program the best there is... The Clinical Documentation Improvement Specialist's Handbook, Second Edition, is an all-inclusive reference to help readers implement a comprehensive clinical documentation improvement (CDI) program with in-depth information on all the essential responsibilities of the CDI specialist. This edition helps CDI professionals incorporate the latest industry guidance and professional best practices to enhance their programs. Co-authors Heather Taillon, RHIA, and Marion Kruse, MBA, RN, combine their CDI and coding expertise to explain the intricacies of CDI program development and outline the structure of a comprehensive, multi-disciplinary program. In this edition you will learn how to: Adhere to the latest government and regulatory initiatives as they relate to documentation integrity Prepare for successful ICD-10 transition by analyzing your CDI program Step up physician buy-in with the improved education techniques Incorporate the latest physician query guidance from the American Health Information Management Association (AHIMA) Table of Contents Chapter 1: Building the CDI Program Chapter 2: CDI and the healthcare system Chapter 3: Application of coding guidelines Chapter 4: Compliant physician queries Chapter 5: Providing physician education Chapter 6: Monitoring the CDI program What's new in the Second Edition? Analysis of new industry guidance, including: AHIMA's Managing an Effective Query Process and Guidance for Clinical Documentation Improvement Programs. CMS guidance from new IPPS regulations, MLN Matters articles, Quality Improvement Organizations, and the Recovery Audit Contractor (RAC) program, among others Strategies to help you incorporate the guidance into your CDI program. Tools to help you interpret MAC initiatives and RAC focus areas to enhance your CDI program and help prevent audit takebacks New sample queries, forms, tools, and industry survey data BONUS TOOLS! This book also includes bonus online tools you can put to use immediately! Sample query forms Sample job descriptions for CDI managers, and CDI specialists Sample evaluation form for CDI staff Sample pocket guide of common documentation standards
  clinical documentation specialist education: CPT Professional 2022 American Medical Association, 2021-09-17 CPT(R) 2022 Professional Edition is the definitive AMA-authored resource to help healthcare professionals correctly report and bill medical procedures and services.
  clinical documentation specialist education: Medical Transcription Fundamentals Diane Gilmore, 2012 Unlike other textbooks that discuss medical concepts in complex and abstract terms, this book outlines the fundamentals of medical specialties in a format that is easy to understand--Provided by publisher.
  clinical documentation specialist education: Principles and Practice of Clinical Research John I. Gallin, Frederick P Ognibene, 2011-04-28 The second edition of this innovative work again provides a unique perspective on the clinical discovery process by providing input from experts within the NIH on the principles and practice of clinical research. Molecular medicine, genomics, and proteomics have opened vast opportunities for translation of basic science observations to the bedside through clinical research. As an introductory reference it gives clinical investigators in all fields an awareness of the tools required to ensure research protocols are well designed and comply with the rigorous regulatory requirements necessary to maximize the safety of research subjects. Complete with sections on the history of clinical research and ethics, copious figures and charts, and sample documents it serves as an excellent companion text for any course on clinical research and as a must-have reference for seasoned researchers.*Incorporates new chapters on Managing Conflicts of Interest in Human Subjects Research, Clinical Research from the Patient's Perspective, The Clinical Researcher and the Media, Data Management in Clinical Research, Evaluation of a Protocol Budget, Clinical Research from the Industry Perspective, and Genetics in Clinical Research *Addresses the vast opportunities for translation of basic science observations to the bedside through clinical research*Delves into data management and addresses how to collect data and use it for discovery*Contains valuable, up-to-date information on how to obtain funding from the federal government
  clinical documentation specialist education: Medical Records Specialist National Learning Corporation, 2019-02 The Medical Records Specialist Passbook(R) prepares you for your test by allowing you to take practice exams in the subjects you need to study. It provides hundreds of questions and answers in the areas that will likely be covered on your upcoming exam, including but not limited to: abstracting information from medical records; distinguishing between primary and differential diagnoses; assigning codes; medical terminology; completing forms; and more.
  clinical documentation specialist education: Improving Healthcare Quality in Europe Characteristics, Effectiveness and Implementation of Different Strategies OECD, World Health Organization, 2019-10-17 This volume, developed by the Observatory together with OECD, provides an overall conceptual framework for understanding and applying strategies aimed at improving quality of care. Crucially, it summarizes available evidence on different quality strategies and provides recommendations for their implementation. This book is intended to help policy-makers to understand concepts of quality and to support them to evaluate single strategies and combinations of strategies.
  clinical documentation specialist education: Clinical Documentation Specialist - The Comprehensive Guide VIRUTI SHIVAN, Dive into the essential world of clinical documentation with Clinical Documentation Specialist - The Comprehensive Guide, a pivotal resource designed for healthcare professionals committed to excellence in patient care through meticulous record-keeping. This guide offers a deep dive into the principles of accurate and compliant medical documentation, highlighting its critical role in ensuring optimal patient outcomes and the seamless operation of healthcare systems. With an emphasis on practical strategies, real-world applications, and the latest compliance standards, this book serves as an invaluable tool for both aspiring and experienced clinical documentation specialists. By focusing on enhancing communication between healthcare providers and supporting the delivery of high-quality care, it addresses the challenges and complexities of modern medical documentation practices. Without relying on images or illustrations for clarity, the guide stands out for its comprehensive coverage and insightful analysis, making it a unique addition to the professional library of healthcare providers. It transcends basic instructional material by weaving in theoretical knowledge with actionable advice, empowering readers to navigate the nuanced landscape of healthcare documentation with confidence. The absence of visual elements is more than compensated for by the depth of knowledge and the engaging writing style, ensuring that readers are equipped with the knowledge and skills necessary to make a significant impact in their roles as guardians of patient information and care continuity.
  clinical documentation specialist education: Conditions of Participation for Hospitals United States. Social Security Administration, 1966
  clinical documentation specialist education: The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition Jennifer Avery, Cheryl Ericson, 2013-05-07 The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition Now in its second edition, The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only guide to address ICD-10 from the CDI point of view. Written by CDI experts and ICD-10 Boot Camp instructors, it explains the ICD-10 documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. In it you'll find the specific documentation requirements to appropriately code a variety of conditions. The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition, not only outlines the changes coming in October 2014, it provides detailed information on how to assess staffing needs, training requirements, and implementation strategies. The authors--an ICD-10 certified coder and CDI specialist--collaborated to create a comprehensive selection of ICD-10 sample queries that facilities can download and use to jumpstart their ICD-10 documentation improvement efforts. Develop the expertise and comfort level you need to manage this important industry change and help your organization make a smooth transition. The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition, is part of the library of products and services from the Association of Clinical Documentation Improvement Specialists (ACDIS). ACDIS members are CDI professionals who share the latest tested tips, tools, and strategies to implement successful CDI programs and achieve professional growth. Member benefits include a quarterly journal, members-only Web site, quarterly networking conference calls, discounts on conferences, and more. WHAT'S NEW? Completely revised to accommodate changes in ICD-10 implementation dates Dozens of targeted ICD-10 physician queries Updated ICD-10 benchmarking reports BENEFITS Sample ICD-10 queries Specificity requirements and clinical indicators by disease type and body system Staff training and assessment tools TABLE OF CONTENTS Chapter 1: ICD-10 primer Chapter 2: Conventions and Guidelines Chapter 3: Physician queries Chapter 4: CDI target areas Chapter 5: ICD-10-CM/PCS Provider Education
  clinical documentation specialist education: Handbook of Home Health Standards Tina M. Marrelli, 2011-06-30
  clinical documentation specialist education: Managed Care Credentialing Amy N. Niehaus, 2019 The role of the MSP is expanding to include payer enrollment and delegated credentialing responsibilities for managed care organizations. Traditionally siloed, MSPs are now beginning to take on both responsibilities, which means they must learn the nuances of managed care credentialing as well as the regulatory and accreditation requirements of NCQA, CMS, and URAC. Managed Care Credentialing: Compliance Strategies for Health Plans, CVOs, and Delegated Entities provides the answers to MSPs' inevitable questions as they begin to manage the tasks of payer enrollment and delegated credentialing. Author Amy M. Niehaus guides readers through each payer's requirements, the differences between hospital and managed care credentialing, and how to help their organization establish delegated credentialing agreements and prepare for audits. As new and existing MSP responsibilities begin to collide, this resource also outlines ways MSPs can modify their current processes to reduce duplication of efforts and develop a comprehensive and compliant managed care credentialing program. Whether you are new to managed care credentialing or are taking on delegated credentialing responsibilities, this book will help you: Learn the regulatory and accreditation requirements related to managed care credentialing Streamline the provider enrollment process through delegation Meet your organizational goals of compliance, operational efficiency, cost savings, and practitioner satisfaction Identify the differences between hospital and managed care credentialing
  clinical documentation specialist education: Taking Action Against Clinician Burnout National Academies of Sciences, Engineering, and Medicine, National Academy of Medicine, Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being, 2020-01-02 Patient-centered, high-quality health care relies on the well-being, health, and safety of health care clinicians. However, alarmingly high rates of clinician burnout in the United States are detrimental to the quality of care being provided, harmful to individuals in the workforce, and costly. It is important to take a systemic approach to address burnout that focuses on the structure, organization, and culture of health care. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being builds upon two groundbreaking reports from the past twenty years, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, which both called attention to the issues around patient safety and quality of care. This report explores the extent, consequences, and contributing factors of clinician burnout and provides a framework for a systems approach to clinician burnout and professional well-being, a research agenda to advance clinician well-being, and recommendations for the field.
  clinical documentation specialist education: The Clinical Documentation Improvement Specialist's Guide to ICD-10 Glenn Krauss, 2011-03 Take charge of ICD-10 documentation requirements The implementation of ICD-10 brings with it new documentation requirements that will have a significant impact on the work of your CDI team. The higher degree of specificity of information needed to code accurately will have a direct correlation to reimbursement and compliance. CDI specialists need a firm understanding of the new code set, and the rules that govern it, to obtain the appropriate level of documentation from physicians. The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only book that addresses ICD-10 from the CDI point of view. Written by CDI experts, it explains the new documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. You'll find the specific documentation requirements to appropriately code conditions such as heart failure, sepsis, and COPD. Learn from your peers The Clinical Documentation Improvement Specialist's Guide to ICD-10 includes case studies from two hospitals that have already begun ICD-10 training so you can use their timelines as a blue print to begin your organization's training and implementation. ICD-10 implementation happens in 2013. It's not too soon to start developing the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. Benefits: * Tailored exclusively for CDI specialists * Side-by-side comparison of what documentation is necessary now v. what will be required starting October 1, 2013 * Timelines to train physicians in new documentation requirements to ensure readiness by implementation date * Strategies and best practices to ensure physician buy-in
  clinical documentation specialist education: The Future of Nursing Institute of Medicine, Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, 2011-02-08 The Future of Nursing explores how nurses' roles, responsibilities, and education should change significantly to meet the increased demand for care that will be created by health care reform and to advance improvements in America's increasingly complex health system. At more than 3 million in number, nurses make up the single largest segment of the health care work force. They also spend the greatest amount of time in delivering patient care as a profession. Nurses therefore have valuable insights and unique abilities to contribute as partners with other health care professionals in improving the quality and safety of care as envisioned in the Affordable Care Act (ACA) enacted this year. Nurses should be fully engaged with other health professionals and assume leadership roles in redesigning care in the United States. To ensure its members are well-prepared, the profession should institute residency training for nurses, increase the percentage of nurses who attain a bachelor's degree to 80 percent by 2020, and double the number who pursue doctorates. Furthermore, regulatory and institutional obstacles-including limits on nurses' scope of practice-should be removed so that the health system can reap the full benefit of nurses' training, skills, and knowledge in patient care. In this book, the Institute of Medicine makes recommendations for an action-oriented blueprint for the future of nursing.
  clinical documentation specialist education: CDI Workbook Sheila Duhon, 2018-09
  clinical documentation specialist education: Risk Adjustment Documentation and Coding Sheri Poe Bernard, 2020-03-02 Risk-adjustment practices consider chronic diseases as predictors of future health care needs and expenses. Correct and detailed documentation and compliant diagnosis coding are critical for proper risk adjustment. Risk Adjustment Documentation & Coding, 2nd Edition provides: Risk-adjustment parameters to improve documentation related to severity of illness and chronic diseases. Code abstraction guidelines and recommendations to improve diagnostic coding accuracy without causing financial harm to the practice or health facility. Chronic disease ICD-10-CM coding summaries for quick reference and study. The impact of risk-adjustment coding (hierarchical condition category (HCC) coding) on a practice should not be underestimated: More than 75 million Americans are enrolled in risk-adjusted insurance plans. This population represents more than 20% of those insured in the United States. Insurance risk pools under the Affordable Care Act include risk adjustment. CMS has proposed expanding audits on risk-adjustment coding. FEATURES AND BENEFITS Five chapters delivering an overview of risk adjustment, common administrative errors, best practices, and guidance for development of internal risk-adjustment coding policies. Ten chronic disease ICD-10-CM coding summaries for quick reference and study. Two appendices offering mappings and tabular information of ICD-10-CM codes that risk-adjust to HCCs and RxHCCs. Learning and design features: Vocabulary terms highlighted within the text and defined at the bottom of the page. Advice/Alert Notes that highlight important coding and documentation advice from federal regulatory sources. Sidebars that provide derivative story and additional information, such as Coding Tips that guide coders with practical advice from sources like AHA's Coding Clinic and cautionary notes about conflicts and exceptions Clinical Examples that underscore key documentation issues for risk adjustment Clinical Coding Examples that provide snippets or full encounter notes and codes to illustrate risk-adjustment coding and documentation concepts Documentation tips that highlight recommendations to physicians regarding what should be included in the medical record or how ICD-10-CM may classify specific terms Examples that explain difficult concepts and promote understanding of those concepts as they relate to a section FYI call outs that provide quick facts Abstract & Code It! exercises that test diagnosis abstraction and coding skills (exclusive to Chapter 4) Extensive end-of-chapter Evaluate Your Understanding sections that include multiple-choice questions, true-or false questions, audit and Internet-based exercises. Two downloadable course tests and slide presentations for each chapter. Exclusive content for academic educators: A test bank containing 100 questions and a mock risk-adjustment certification exam with 150 questions.
  clinical documentation specialist education: Step-By-Step Medical Coding, 2017 Edition Carol J. Buck, 2016-12-06 Resource ordered for the Health Information Technology program 105301.
  clinical documentation specialist education: Cancer Registry Management Herman R. Menck, 2011
  clinical documentation specialist education: Nursing Informatics American Nurses Association, 2015 The second edition of Nursing Informatics: Scope and Standards of Practice is the most comprehensive, up-to-date resource available in this subject area. The book covers the full scope of nursing informatics and outlines the competency level of nursing practice and professional performance expected from all informatics nurses and nurse specialists. In addition, it details the nursing informatics competencies needed by any RN, spans all nursing careers and roles, and reflects the impact of informatics in any health care practice environment. This is a must-read for nurses, as informatics touche.
  clinical documentation specialist education: HCPCS Level II Professional , 2020-12 Accurately report supplies and services for physician, hospital outpatient, and ASC settings with the Ingenix HCPCS Level II Professional. Use this comprehensive reference for the HCPCS code set that focuses on management of reimbursement. Organized to enhance coding capability without added complexity, this user-friendly book provides coders with a reference to increase efficiency and reduce workload by helping them locate the right code the first time.
  clinical documentation specialist education: Principles of Healthcare Reimbursement and Revenue Cycle Management, Eighth Edition Anne Casto, Susan White, 2023-10-02
  clinical documentation specialist education: Nursing Professional Development Ana, 2014-05-14 Revision of: Scope and standards of practice for nursing professional development. 2000.
The Clinical Documentation Integrity Specialist’s ... - ACDIS
program draws from experienced clinical documentation integrity specialists to establish criteria for competency in the broad and multidisciplinary bodies of knowledge critical to the role of clinical …

Clinical Documentation Improvement Toolkit - AHIMA Body of …
Clinical documentation is the foundation of every health record in every setting. Clinical documentation is any manual or electronic notation made by a clinical care provider or their …

CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST
The Clinical Documentation Improvement Specialist (CDIS) is responsible for competency in coordinating and performing day to day operations, providing concurrent and/or retrospective …

Purpose of Compliant Documentation Management Program
Purpose of Compliant Documentation Management Program • Clinical Documentation Specialist acts as a liaison between concurrent documentation and coding. • CDS reviews active charts and …

Title: Clinical Documentation Specialist (CDS) - enjoincdi.com
• Analyze medical record documentation and other references such as MAR, Labs, Orders, etc. to validate clinical validity of reportable diagnoses and procedures, identify viable working DRG, …

Clinical Documentation Integrity (CDI) Best Practices
CDI programs facilitate accurate representation of patient’s clinical status. Nurses/CDSs (clinical documentation specialists) have strong clinical background to assist in translating, interpreting …

Outpatient Clinical Documentation Improvement (CDI): An …
CDI, the ACDIS Advisory Board has written the following white paper. Its goal is to explain what typically constitutes outpatient CDI, and to discuss ways in which CDI specialists can be …

Clinical Documentation Improvement TOOLKIT - CMS-ITU …
Clinical documentation is the foundation of every health record in every setting. Clinical documentation is any manual or electronic notation made by a clinical care provider or their …

2022 Candidate Handbook - ACDIS
Clinical Documentation Specialist Certification overview The purpose of becoming a CCDS and/or a CCDS-O is to recognize that those individuals who perform the role of a clinical documentation …

Clinical Documentation Improvement Specialist
Working independently, the Clinical Documentation Improvement (CDI) Specialist performs audits of the medical record to ensure the capture of complete and accurate provider documentation and …

AN ESSENTIAL GUIDE TO CLINICAL DOCUMENTATION …
What is Clinical Documentation Improvement (CDI) and Why is it Important? Because clinical documentation is at the core of every health care encounter, it must be complete, precise and …

CDI Progression Ladder - AHIMA
AHIMA® strives to provide the CDI Industry with educational material and products to support all stages of a CDI professionals career. The items in the CDI Progression Ladder represent the …

Clinical Documentation Improvement TOOLKIT
• Obtain clinical documentation that captures the patient severity of illness and risk of mortality • Identify and clarify missing, conflicting, or nonspecific physician documentation related to

Physician Education in Clinical Documentation Improvement
The Clinical Documentation Improvement video podcast series is designed to review key clinical indicators and other information for healthcare providers, necessary for accurate and concise …

Clinical Documentation Improvement Playbook - NCHA
Clinical documentation improvement (CDI) programs play a vital role in today’s healthcare environment. The growth of the U.S. healthcare industry has resulted in increasingly demanding …

2025 Clinical Documentation Improvement Training Certified ...
The central focus of all clinical documentation should be to demonstrate the quality of care provided to the patient with detail and accuracy to facilitate optimum patient care .

Clinical Documentation Improvement Staff Education Series …
Provide education to the clinical documentation specialists to enhance their knowledge of documentation improvement concepts and coding guidelines. Program Objectives: 1. Review …

2020 Candidate Handbook - ACDIS
perform the role of a clinical documentation specialist and who have a diverse set of concurrent, prospective, and retrospective medical record review skills, clinical knowledge, and knowledge of …

Clinical Documentation Specialist Job Description
Education and Training: To become a clinical documentation specialist requires a bachelor’s degree in health information technology or at least an associate’s degree in applied science

Defining the CDI specialist’s roles and responsibilities
Defining the CDI specialist’s roles and responsibilities Director’s note: This position paper seeks to clarify the role of the clin-ical documentation improvement specialist (CDIS) and provide …

The Clinical Documentation Integrity Specialist’s ... - ACDIS
program draws from experienced clinical documentation integrity specialists to establish criteria for competency in the broad and multidisciplinary bodies of knowledge critical to the role of …

Physician Education in Clinical Documentation Improvement
The Clinical Documentation Improvement video podcast series is designed to review key clinical indicators and other information for healthcare providers, necessary for accurate and concise …

2022 Candidate Handbook - ACDIS
ACDIS certifications Certified Clinical Documentation Specialist (CCDS) and Certified Clinical Documentation Specialist - Outpatient (CCDS-O). Please refer to the contents of this …

Clinical Documentation Integrity’s Quality and Cost …
Clinical Documentation Integrity’s Quality and Cost Implications "Partnering with clinical documentation experts will safeguard patient documentation and confirm that the medical …

Defining the CDI specialist’s roles and responsibilities
Defining the CDI specialist’s roles and responsibilities Director’s note: This position paper seeks to clarify the role of the clin-ical documentation improvement specialist (CDIS) and provide …

Outpatient Clinical Documentation Improvement (CDI): An …
At a minimum, a CDI specialist working in the outpatient setting must understand the differences between OPPS methodology and the inpatient prospective payment system (IPPS).

Utilization Review and CDI: Collaboration Is the Key to Success
Clinical Documentation Specialist • Perform advanced chart review • Query the provider for additional information for coding accuracy • Documentation guidelines to accurately represent …

The Promise of AI for CDI
allowing the clinical documentation specialist (CDS) to create and send electronic queries. In recent years, AI has transformed the world of CDI through rapidly evolving innovations that …

Building a Resilient CDI: Second Level Review
clinical documentation. She plans and supports ongoing communication and education to staff and physicians, creates and disseminates reports and action plans, and is accountable for the …

CCDS-O experience prerequisites - ACDIS
Candidates for the Certified Clinical Documentation Specialist‐Outpatient (CCDS‐O) exam must: List their documentation specialist experience. Applications may be audited to verify work …