Download or read book The Clinical Documentation Improvement Specialist s Guide to Audit Defense written by Trey La Charite and published by . This book was released on 2017-01-30 with total page 168 pages. Available in PDF, EPUB and Kindle. Book excerpt: CDI Field Guide to Denials Prevention and Audit Defense Trey La Charit�, MD, FACP, SFHM, CCDS How can your CDI program help defend your facility's medical records and claims submissions from "recovery raiders" to ensure the facility receives the appropriate reimbursement for its patient care? The world of denials prevention and audit defense is filled with a host of watchdog agencies--an alphabet soup of acronyms--to audit claims and take back funds for inappropriate submissions. Your hospital must work to protect its reimbursement, and your CDI program can help. With more than a dozen years' experience working with CDI staff to defend claims and tighten procedures around documentation for auditor targets, author Trey La Charit�, MD, FACP, SFHM, CCDS, provides step-by-step tools to help your program improve its denials prevention efforts. This resource will help CDI professionals: Understand the scope of Recovery Auditors in private and governmental reimbursement efforts Identify various audit contractors and their respective scope of work Explain the importance of CDI and query compliance in denials prevention Identify potential documentation denial risks associated with electronic health records Establish effective appeals processes
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 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 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 Clinical Documentation Improvement Specialists Complete Training Guide written by Laurie L. Prescott (R. N.) and published by . This book was released on 2014 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
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 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 Medical Record Auditor written by Deborah J. Grider and published by American Medical Association Press. This book was released on 2015 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Providing in-depth guidance for proper review of medical documentation in today's changing medical environment, this fourth edition of the Medical Record Auditor is full of new content. New topics include electronic health records (EHR), ICD-10 coding, Health Information Management and many other issues essential for maintaining compliance. Learn critical auditing fundamentals, read dozens of case studies, use the checkpoint exercises to test your knowledge, and download actual audit forms to help improve your process. Features and Benefits - New content addresses EHRs, ICD-10 coding and more - Downloadable forms. One copy of each audit form is included, but all forms are downloadable from website - Case studies. Ten different specialties are featured with more than 80 total case studies - Checkpoint exercises. Test your knowledge to confirm comprehension of new content
Download or read book The Physician Advisor s Guide to Clinical Documentation Improvement written by Trey La Charité and published by . This book was released on 2014 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book The Physician Documentation Improvement Pocket Guide Third Edition written by Cheryl Ericson and published by . This book was released on 2014-10-22 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Physician Documentation Improvement Pocket Card, Third Edition (Packs of 25) Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer Sold in packages of 25! Use the Physician Documentation Improvement Pocket Card, Third Edition, to help your physicians remember key documentation points. The six-panel card includes everything from documentation basics to severity of illness clinical indicators. Updated for 2014, this third edition simplifies tips to common documentation improvement opportunities. And it fits easily in the physician's pocket! Start your CDI physician education efforts with the accompanying online instruction manual and help physicians understand common documentation gaps. This product: Provides documentation basics for the short-term acute care inpatient setting Includes tips for discharge summary documentation Details documentation needed to establish a condition as a reportable diagnosis Presents key reminders for documentation to reflect patient acuity Offers advice for how to differentiate among acute, chronic, and resolved conditions Helps providers translate commonly vague documentation of a patient's chief complaint into a more precisely associated diagnosis Includes both printed pocket card and online PDF formats Folds for physicians to carry in their pockets and is laminated for durability and easy cleaning The latest edition of the Physician Documentation Improvement Pocket Card helps you improve patient acuity and severity by focusing on common areas of vague and nonspecific physician documentation. ACDIS Education Director and lead CDI Boot Camp instructor Cheryl Ericson brings her vast experience to bear in creating a simple to follow, easy to use tip sheet and accompanying user's guide to help improve your physicians' documentation. Online user manual will explain how to use the pocket cards and explain some CDI basics.
Download or read book Clinical Documentation Improvement Specialist s Handbook written by Colleen Garry and published by Hcpro Incorporated. This book was released on 2014-05-14 with total page 172 pages. Available in PDF, EPUB and Kindle. Book excerpt: Improving documentation is no easy task CDI professionals have never had one easy-to-read, inclusive reference to help them implement a CDI program, understand the fundamentals of ICD-9-CM coding, query physicians, and encourage interdepartmental communication. In theory, physicians should document their entire thought process, including ruling conditions in and out. But it's not that simple, and in light of MS-DRGs, it requires significant physician education and retraining. You need a blueprint for success.. Your blueprint has arrived! At last, here is a guide for CDI specialists. The Clinical Documentation Improvement Specialist's Handbook is your essential partner for creating a CDI program, staffing your program, querying physicians, and understanding how documentation affects code selection and data quality As a CDI specialist you need answers now In light of Medicare Severity DRGs (MS-DRG), detailed documentation and accurate capture of complications and comorbidities (CCs) has made the CDI specialist's role more important and more demanding than ever. This handbook will enhance your ability to gather the right information the first time--and every time Author Colleen Garry, RN, BS, has compiled case studies that document best practices and reference several different CDI models so that you can select the one that's right for your hospital's CDI success. In addition, you'll be privy to an executive summary of HCPro's exclusive CDI survey that solicited more than 800 responses. Learn how other hospitals are handling CDI and choosing the model that works best for them. * work with physicians to obtain detailed, appropriate documentation * maintain compliance when performing physician queries * convey return on investment for a CDI program Customizable CD-ROM included Your copy of The Clinical Documentation Improvement Specialist's Handbook includes a CD-ROM loaded with all of the working tools you'll find in the book. Among them
Download or read book Clinical Documentation Specialist The Comprehensive Guide written by Viruti Shivan and published by . This book was released on 2024-04-25 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Mastering the Art of Medical Record Accuracy and Compliance for Enhanced Patient Care 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 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!
Download or read book The Clinical Documentation Improvement Specialist s Handbook written by Ruthanne Russo and published by . This book was released on 2008-01-01 with total page 166 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Government Auditing Standards 2018 Revision written by United States Government Accountability Office and published by Lulu.com. This book was released on 2019-03-24 with total page 234 pages. Available in PDF, EPUB and Kindle. Book excerpt: Audits provide essential accountability and transparency over government programs. Given the current challenges facing governments and their programs, the oversight provided through auditing is more critical than ever. Government auditing provides the objective analysis and information needed to make the decisions necessary to help create a better future. The professional standards presented in this 2018 revision of Government Auditing Standards (known as the Yellow Book) provide a framework for performing high-quality audit work with competence, integrity, objectivity, and independence to provide accountability and to help improve government operations and services. These standards, commonly referred to as generally accepted government auditing standards (GAGAS), provide the foundation for government auditors to lead by example in the areas of independence, transparency, accountability, and quality through the audit process. This revision contains major changes from, and supersedes, the 2011 revision.
Download or read book Clinical Trials Audit Preparation written by Vera Mihajlovic-Madzarevic and published by John Wiley & Sons. This book was released on 2010-09-29 with total page 186 pages. Available in PDF, EPUB and Kindle. Book excerpt: A must-have guide for any professional in the drug manufacturing industry The Good Clinical Practice (GCP) audit is a tedious but necessary exercise that assures that all parties do their job properly and in compliance with the applicable FDA code. Clinical Trials Audit Preparation demystifies the audit process for all parties involved, including clinical research sponsors, clinical investigators, and institutional review boards. This book provides a step-by-step explanation of the FDA audit procedures for clinical trials and of how pharmaceutical companies, clinical investigators, and institutional review boards should prepare for regulatory audits. The book emphasizes the processes and procedures that should be implemented before a clinical audit occurs, making this an imperative guide to any professional in the drug manufacturing industry, including drug manufacturing companies, regulatory affairs personnel, clinical investigators, and quality assurance professionals. Among the topics discussed: Good Clinical Practices and therapeutic product development in clinical research The roles of the sponsor of a clinical investigation, the IRB, or independent ethics committee The roles and responsibilities of the clinical trial investigator The inspection preparation The Audit Report and the Form 483 Warning letters issued to clinical investigators and clinical trial sponsors and their impact on product development
Download or read book The Provider Query Toolkit written by Karen Newhouser and published by . This book was released on 2020-04 with total page 146 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Provider Query Toolkit: A Guide to Compliant Practices provides a comprehensive analysis of query guidelines and easy-to-follow strategies to improve query processes. This valuable resource, perfect for both the new CDI specialist and those looking for a refresher on CDI query fundamentals, examines recent changes in coding and payer nuances, denial trends, query compliance, and quality programs impacting the CDI specialist.
