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 The Physician Documentation Improvement Pocket Guide Second Edition written by Hcpro Inc. Staff and published by . This book was released on 2012-12-03 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Physician Documentation Improvement Pocket Guide, Second Edition (Packs of 25) Documentation improvement help for your physicians at their fingertips.Sold in packages of 25 Use the "Physician Documentation Improvement Pocket Guide, ""Second 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 2013, this second edition includes information physicians need for their CPT and evaluation and management (E/M) documentation. 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: Contains common severity of illness documentation tips Includes physician E/M and CPT documentation reminders Offers guidance for physician CDI training efforts Includes both printed pocket card and online PDF formats
Download or read book Physician Documentation Pocket Guide 25 Pack written by Pamela P Bensen and published by . This book was released on 2010-10 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
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 2014-04-30 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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
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 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 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 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 How To Manual for Rehab Documentation Third Edition written by Rick Gawenda and published by HC Pro, Inc.. This book was released on 2009-04-06 with total page 183 pages. Available in PDF, EPUB and Kindle. Book excerpt: The How-To Manual for Rehab Documentation, Third Edition A Complete Guide to Increasing Reimbursement and Reducing Denials Rick Gawenda, PT Up-to-speed with Medicare documentation requirements for 2009 and beyond? Increase cash flow and reduce Medicare claim denials by using strategies provided in the Third Edition of The How-To Manual for Rehab Documentation. Written by national consultant Rick Gawenda, PT. Since our last edition, there have been significant changes to the rules and regulations surrounding documentation in therapy settings. And now that the RACs are underway it is even more important to have accurate and thorough documentation. Mistakes can lead to delayed payments and denials, so how do ensure that you are in compliance with the current guidelines? Make it easy. Order your copy of The How-To Manual for Rehab Documentation, Third Edition: A Complete Guide to Increasing Reimbursement and Reducing Denials. Written by author and national consultant Rick Gawenda, PT, of Gawenda Seminars, this book and CD-ROM setfocuses on the clinical aspects of documentation and offers proven methods to strengthen documentation and decrease the frequency of denials. Gawenda encourages b documentation methods that have worked for him and help you conquer potentially tough concepts such as maintenance therapy and CPT codes. What's new in the third edition? Clarification of certification and re-certification requirements regarding how long they are valid for and how soon they need to be signed Explanation of delayed certification Tips to write function-based short- and long-term goals Updated examples of well-written goals Updated payer documentation guidelines for evaluations, progress reports, daily notes, discharge reports, and re-evaluations The How-To Manual for Rehab Documentation, Third Edition: A Complete Guide to Increasing Reimbursement and Reducing Denials outlines proper documentation strategies starting from the moment a patient registers and receives treatment to billing for time and services. Gawenda encourages b documentation methods that have worked for him and help you conquer potentially tough concepts such as maintenance therapy and CPT codes. This comprehensive book and CD-ROM, helps you: Improve therapy billing through better documentation Prevent denials as a result of better documentation practices Maintain quality assurance through proper documentation Optimize your reimbursement from both Medicare and third-party payers Avoid audits and targeted medical reviews Document care in a more efficient way Take the critical steps to verify therapy benefit coverage prior to a patient's initial visit Support skilled therapy services with inclusion of required documentation Understand Medicare certification and recertification time frames and requirements for all therapy settings Understand and use the most commonly used CPT codes and modifiers in rehabilitation therapy Table of Contents: Chapter 1: The Role of the Registration Staff Registration Basics Benefit Verification Preregistering Chapter 2: Initial Documentation Evaluation Format Documentation Components Evaluation Process Objective Criteria Assessment Documentation Goals POC Documentation Creating a Solid Foundation Chapter 3: Certification and Recertification Physician Referrals Physician Referral Denials Outpatient Therapy Settings Certification and Recertification SNF Part A Therapy Services Reimbursed Under the Prospective Payment System (PPS) Home Health Agency Part A Therapy Services Chapter 4: Daily Documentation Daily Documentation Documentation Requirements Home Exercise Programs (HEPs) Plan Documentation Chapter 5: Progress Reports, Discharge Reports, and Reevaluations Progress Reports Discharges Reevaluations Chapter 6: Maintenance Therapy What is an FMP? Coverage Criteria Documentation Requirements Billing Cover All Your Bases Chapter 7: Wound Care Under Medicare Discharge Criteria Additional Pointers Appendix A: Navigating the CMS Web site Getting Started Final Word Make it easy to understand CMS' documentation guidelines No need to download and interpret the guidance from the CMS Web site yourself. Author Rick Gawenda, PT, has done the work for you. His documentation practices are sure to help you receive optimal compensation for the services you perform as a therapist. Nearly half of all rehab claim denials are STILL due to improper documentation. Ensure proper documentation for services provided and decrease the frequency of denials. Order The How-To Manual for Rehab Documentation, Third Edition: A Complete Guide to Increasing Reimbursement and Reducing Denials today!
Download or read book Guide to Clinical Documentation written by Debra D. Sullivan and published by . This book was released on 2018-08-16 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Learning objectives in each chapter to help you recognize important concepts at the beginning of the chapter, and reinforce what is summarized at the end of each chapter Coverage of -problem-oriented medical records, patients with multiple complaints or multiple conditions Hands-on, problem-based exercises Worksheets at the end of each chapter Examples of "good" and "bad" documentation for evaluation Real-life case studies that illustrate the potential consequences of poor or inaccurate documentation. Explanations of use and terminology of ICD-10-CM codes in billing Boxes highlighting medicolegal considerations.
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 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 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 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 Medical Informatics written by Kenneth R. Ong and published by CRC Press. This book was released on 2015-03-27 with total page 382 pages. Available in PDF, EPUB and Kindle. Book excerpt: This third edition of HIMSS' award-winning, bestseller explores how clinicians, patients, and health IT stakeholders are collaborating to support high-value care through health IT. Medical Informatics: An Executive Primer continues to explore information technologies applied in hospital settings, at the physician's office and in patients' homes to
Download or read book Documentation Improvement Handbook for the Medical Staff written by Jean S. Clark and published by Hcpro Incorporated. This book was released on 2003 with total page 22 pages. Available in PDF, EPUB and Kindle. Book excerpt:
