Download or read book Clinical Documentation Improvement CDI Made Easy 2nd Edition written by Anthony Nkwuaku and published by Createspace Independent Publishing Platform. This book was released on 2018-02-24 with total page 264 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
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 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 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 Clinical Documentation Improvement written by Rn Phn Nkwuaku, Msn Cphq and published by Createspace Independent Publishing Platform. This book was released on 2015-12-17 with total page 246 pages. Available in PDF, EPUB and Kindle. Book excerpt: Clinical Documentation Improvement (CDI) Made Easy is a great resource and reference that every Clinical Documentation Improvement Specialist/Professional (CDIS/CDIP), coder, physician champion/advisor, and others involved in the CDI must have. The book is a compendium of sound clinical knowledge and experience, clinical documentation expertise, and quality, which will help the CDIS/CDIP and others maximize their potentials in performing their core duties. Whether you are a new CDIS trying to learn CDI or an experienced CDIS hoping to stay current with CDI world, or involved in the CDI, this book will be very valuable to you. Remember, accurate and quality documentation is a reflection of great patient care. "If it wasn't documented, and documented accurately, it never happened." This book clearly explained various query opportunities by Major Disease Classifications (MDCs) with some sample queries. It defines and analyses different disease processes, creates CDIS awareness and what to look for under various MDCs, ICD-10-CM/PCS, explained current CMS Pay for Performance (P4P), and the CDI responsibility under P4P, explained some pertinent coding guidelines, 2016 Official Coding Guidelines for Coding and Reporting, AHIMA/ACDIS practice brief for queries and compliance, and much more. I have no doubt in my mind that this book is a concise but a comprehensive tool and reference that anyone involved in CDI should always have at his/her side. The Author Anthony O Nkwuaku, RN, PHN, MSN, CPHQ, CCDS is very knowledgeable and experienced as a clinician, clinical instructor, and Clinical Documentation Improvement Specialist.
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 CCDS Exam Study Guide written by and published by HC Pro, Inc.. This book was released on 2010 with total page 155 pages. Available in PDF, EPUB and Kindle. Book excerpt:
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 Manual of Inpatient Psychiatry written by Michael I. Casher and published by Cambridge University Press. This book was released on 2020-03-26 with total page 239 pages. Available in PDF, EPUB and Kindle. Book excerpt: Explores the range of diagnoses found on inpatient psychiatric units providing practical advice in an accessible format for managing patients.
Download or read book The Clinical Documentation Sourcebook written by Donald E. Wiger and published by John Wiley & Sons. This book was released on 2010-02-02 with total page 338 pages. Available in PDF, EPUB and Kindle. Book excerpt: All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.
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 385 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 The Complete Guide to CDI Management written by Cheryl Ericson and published by . This book was released on 2016-01-28 with total page 180 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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
Download or read book Improving Healthcare Quality in Europe Characteristics Effectiveness and Implementation of Different Strategies written by OECD and published by OECD Publishing. This book was released on 2019-10-17 with total page 447 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book CDI Companion for Physician Advisors written by Trey La Charité and published by Hcpro, a Division of Simplify Compliance. This book was released on 2016-11 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: When it comes to clinical documentation, physician advisors have a range of important responsibilities, from query escalation to denials management and everything in between. With all these tasks on their plate, physician advisors are constantly pulled in different directions, making it hard to make the best use of their time. CDI Companion for Physician Advisors: Notes From the Field is designed to help physician advisors structure their time properly and carry out their CDI duties effectively and efficiently. This book will help physician advisors: Find their feet in the CDI role Identify tools to provide effective documentation education for physicians and CDI staff Engage medical staff in documentation improvement efforts Understand common documentation deficiencies for difficult diagnoses such as sepsis, heart failure, and kidney disease Work with their CDI team to tackle advanced record reviews in areas such as quality, audit defense, and outpatient HCCs Figure out how to best structure their time to carry out CDI duties
Download or read book Coding for Medical Necessity Reference Guide First Edition written by AAPC and published by AAPC. This book was released on 2020-03-18 with total page 17 pages. Available in PDF, EPUB and Kindle. Book excerpt: Master coding concepts related to medical necessity and report compliant codes for your services. Revenue loss, rework, payback demands—how much are medical necessity errors costing your practice? And that’s to say nothing of potential civil penalties. Get medical necessity wrong and it’s considered a “knowingly false” act punishable under the FCA. Stay liability-free and get reimbursed for your services with reliable medical necessity know-how. AAPC’s Coding for Medical Necessity Reference Guide provides you with step-by-step tutorials to remedy the range of documentation and coding issues at the crux of medical necessity claim errors. Learn how to integrate best practices within your clinical processes—including spot-checks and self-audits to identify problems. Benefit from real-world reporting examples, Q&A, and expert guidance across specialties to master coding for medical necessity. Learn how to lock in medical necessity and keep your practice safe and profitable: Avoid Medical Necessity Errors with CERT Smarts Rules to Improve Provider Documentation Denials? Pay Attention to Procedure/Diagnosis Linkage Nail Down the Ins and Outs of Time-based Coding Expert Guidance to Fend Off RAC Audits and Denials Beat E/M Coding Confusion with Payer Advice Improve Your ABN Know How with This FAQ
Download or read book 2021 CDI Pocket Guide written by Cynthia Tang and published by . This book was released on 2020-10-15 with total page 328 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book The Coder s Guide to Physician Queries written by Adrienne Commeree and published by . This book was released on 2017-11-27 with total page 120 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book is for new and established coders who are looking to expand their knowledge of queries.
