Download or read book The Clinical Documentation Improvement Specialist s Handbook Second Edition written by Heather Taillon and published by HC Pro, Inc.. This book was released on 2011-01-21 with total page 171 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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

Download or read book Clinical Documentation Enhancement Program written by Alyson D. Raines and published by . This book was released on 2006 with total page 100 pages. Available in PDF, EPUB and Kindle. Book excerpt: Abstract: A medical record is generated on every patient treated in an inpatient hospital or outpatient facility such as a physician office or ambulatory care center. Information within the medical record is the primary source for determining the care a patient receives and it is the primary source of information used to determine reimbursement for care. In order for documentation to accurately reflect the condition and treatment rendered to a patient medical record documentation by healthcare providers must be timely, specific and complete. The issue of documentation is a problem in the healthcare industry. If a facility's data is not accurate, consistent and reliable; the facility is at a risk of collecting inaccurate data, which diminishes the acuity level of the patients they treat, and provides an inaccurate risk profile. As healthcare organizations recognize the importance of clinical documentation, Clinical Documentation Enhancement Programs must be evaluated to measure their impact within a healthcare facility. The major objective of the CDEP was to promote complete and accurate medical record documentation of patient care. Thus, purpose of this study was to determine whether the Documentation Enhancement Program in an academic medical center was accomplishing the program's goals.

Download or read book Clinical Documentation Reference Guide First Edition written by AAPC and published by AAPC. This book was released on 2020-03-12 with total page 13 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book The Clinical Documentation Improvement Specialist s Guide to ICD 10 written by Glenn Krauss and published by HC Pro, Inc.. This book was released on 2011-03 with total page 163 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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

Download or read book The Clinical Documentation Improvement Specialist s Complete Training Guide written by Laurie L. Prescott and published by . This book was released on 2014-10-23 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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

Download or read book Clinical Documentation Improvement written by Pamela Carroll Hess and published by . This book was released on 2015 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:

Download or read book Clinical Documentation Improvement for Outpatient Care written by Pamela Carroll Hess and published by . This book was released on 2018 with total page 394 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book Registries for Evaluating Patient Outcomes written by Agency for Healthcare Research and Quality/AHRQ and published by Government Printing Office. This book was released on 2014-04-01 with total page 396 pages. Available in PDF, EPUB and Kindle. Book excerpt: This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.

Download or read book Clinical Documentation Specialist The Comprehensive Guide written by VIRUTI SHIVAN and published by Viruti Satyan Shivan. This book was released on with total page 232 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book The Physician Advisor s Guide to Clinical Documentation Integrity Second Edition written by Trey La Charité and published by . This book was released on 2020-08 with total page 212 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book The Clinical Documentation Improvement Specialist s Guide to ICD 10 Second Edition written by Jennifer Avery and published by Hcpro, a Division of Simplify Compliance. This book was released on 2013-05-07 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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

Download or read book Clinical Documentation Improvement written by Ruthann Russo and published by American Health Information Management Association. This book was released on 2009-08-01 with total page 203 pages. Available in PDF, EPUB and Kindle. Book excerpt: Cover title includes subtitle: "Achieving excellence."

Download or read book First Steps in Outpatient CDI written by Anny Pang Yuen and published by . This book was released on 2017-06-22 with total page 134 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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

Download or read book Guide to Clinical Documentation written by Debra Sullivan and published by F.A. Davis. This book was released on 2011-12-22 with total page 301 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book The Documentation Improvement Guide to Physician E M written by Glenn A. Krauss and published by . This book was released on 2012-02-27 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Give physicians a crash course in the documentation of E/M services Physicians who provide E/M services must document the necessary clinical information to support their medical decision-making. This is where CDI specialists play an important role, and The Documentation Improvement Guide to Physician E/M can help. This reference guide helps CDI specialists explain to physicians how complete and accurate documentation benefits their E/M payments, prevents medical necessity denials, and provides the information they need to document correctly. This handbook offers the perfect portable reference guide for CDI specialists to educate physicians about E/M documentation. This handbook is provided in packs of 10 so CDI specialists can distribute copies to physicians during documentation improvement education sessions or in response to physician questions and requests for additional information. This reference guide will help CDI specialists: Better understand the complex guidelines that affect physician payment for E/M services Explain the importance of documentation to physicians beyond hospital reimbursement Clarify the purpose of queries and how responding to them benefits physicians' payments and public profiles Encourage physicians to provide adequate documentation that will reduce the number of denials for lack of documented medical necessity Access a comprehensive list of additional online resources to further aid them in their important role Take a look at the table of contents: Chapter 1: E/M Documentation Chapter 2: Components of E/M Chapter 3: Chief Complaint Chapter 4: History of Present Illness Chapter 5: Review of Systems Chapter 6: Past, Family, and Social History Chapter 7: Physical Examination Chapter 8: Medical Decision-Making Chapter 9: Amount and Complexity of Data Chapter 10: Critical Care Chapter 11: Medical Necessity and Clinical Documentation Appendix

Download or read book Evaluation of the Clinical Documentation Improvement Program at a Midwestern Community Hospital written by Linda M. Gall and published by . This book was released on 2008 with total page 108 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Download or read book Bridging the Gap Between Coding and Clinical Documentation Improvement CDI written by Anneleah Williams Bridges and published by . This book was released on 2020-02-14 with total page 102 pages. Available in PDF, EPUB and Kindle. Book excerpt: Physicians play vital roles in the overall quality of patient care. However, HIM professionals and clinical documentation improvement specialists also share essential roles in the healthcare system as guardians of PHI and advocates for continuity of care through consistent documentation and accurate code assignment. Clinical documentation improvement specialists (CDIS) are responsible for the communicative aspects of the process, often serving as a liaison between the provider and the coder. The CDIS ensures that the medical record is complete, there is clinical validation to support diagnoses, and that the medical record is consistent without conflicting or obscure documentation. HIM professionals share some of the responsibility of CDIS in addition to abstracting data from the medical record and assigning the appropriate codes to accurately report the patient's clinical picture.Without the two teams working hand in hand to improve the medical record's documentation, billing errors could ensue, and the quality of patient care is at risk. The process is very detailed and requires a clinical and coding mind to work efficiently. More organizations are calling for their CDIS to learn the fundamentals of coding and for their coders to review the medical record with clinical eyes. Which is whythisresource proves invaluable! Whether you're already skilled in HIM but want to add CDI expertise to your resume, or an existing CDIS looking to update your coding skillset this publication will be of good use to you!