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 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 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 Advanced Practice Providers written by Maria Lofgren and published by Sigma Theta Tau. This book was released on 2023-12-14 with total page 396 pages. Available in PDF, EPUB and Kindle. Book excerpt: “This is a must-read for all healthcare organizational leaders where advanced practice registered nurses (APRNs) and physician assistants (PAs) are a part of the healthcare team. Being able to understand how to best support and utilize this workforce is crucial in the success of any healthcare delivery system. The authors of this book have brilliantly laid out a blueprint to build a strong and engaged APRN/PA staff.” –Risa Zimmerman, MBA, MPAS, PA-C, DFAAPA Director, Office of Advanced Practice Nebraska Medicine “Within these pages lies a treasure trove of evidence-based tools, templates, pitfalls to avoid, and more for anyone who is interested in advanced practice in healthcare. Maria Lofgren and the Iowa team, with learnings from 15+ years creating a sustainable APP model, have given a huge gift to healthcare delivery globally. I’m especially excited about the thoughtful reflections on staying attuned to relationships between providers as well as the figures and sidebars that highlight policy implications and provide specific examples for implementation.” –Ann Williamson, PhD, RN, NEA-BC Former Chief Nurse and Healthcare Executive “With the rapid expansion of advanced practice providers (APPs) nationwide, new APP leaders seek guidance and insight on building a program of fully optimized providers. Lofgren et al. have accomplished this task, providing a complete and comprehensive road map for C-suites and APP leaders to follow, creating the pillars of supporting practice from student to expert for healthcare organizations.” –Bonnie Proulx, DNP, APRN, PNP-BC, FAAN Senior Vice President Physician Enterprise Kaufman Hall Healthcare Management and Consulting Advanced practice providers (APPs) are a quickly growing part of the healthcare workforce, helping to bridge the gap between the demand for physicians and nurses and keeping healthcare costs lower while maintaining a high quality of care. As hospitals, clinics, and healthcare organizations integrate APRNs and PAs into their clinical operations, healthcare leaders need direction on operationalizing these APPs into practice. Advanced Practice Providers: An Operational Guide for Workforce Integration provides a blueprint for organizations—academic, hospital, and clinic-based —as well as academic programs teaching APRNS and PAs to assimilate the uniqueness of the APP group into existing infrastructures, effectively using resources within organizations to help advance healthcare toward higher quality care, patient safety goals, and team care initiatives. TABLE OF CONTENTS Chapter 1: Comparison of Medicine and Nursing Infrastructures and the Growing APP Workforce Chapter 2: Understanding the Organizational Blueprint Chapter 3: Establishing an Infrastructure Chapter 4: APRN and PA Scope of Practice Chapter 5: Establishing an APP Workforce Chapter 6: APP Onboarding Chapter 7: Operationalizing Telehealth Chapter 8: APRN and PA Students Chapter 9: APP Business Pro Forma Chapter 10: Credentialing and Privileging Chapter 11: Organizational Compliance Chapter 12: Professional Development Chapter 13: Mentoring Chapter 14: Metrics That Matter Chapter 15: Team-Based Care Chapter 16: Patient Access Center Chapter 17: Organizational Initiatives Chapter 18: Looking to the Future Appendices ABOUT THE AUTHORS Maria Lofgren, DNP, ARNP, NNP-BC, CPNP, FAANP, is a Clinical Associate Professor and Director of Faculty Practice at the University of Iowa College of Nursing and the Director of Advanced Practice Providers at University of Iowa Health Care. Christine Gust, MBA, PHR, SHRM-CP, is Human Resources Generalist at University of Iowa Health Care, Carver College of Medicine, Office of Advanced Practice Providers. Her work has led to aligning HR strategies to advanced practice provider organizational objectives, policies, programs, and initiatives. Douglas Van Daele, MD, FACS, is a Professor in the Department of Otolaryngology, Head and Neck Surgery at the University of Iowa Carver College of Medicine and is affiliated with the Iowa City Veterans Affairs Health Care System.

Download or read book ICD 10 CM Official Guidelines for Coding and Reporting FY 2021 October 1 2020 September 30 2021 written by Department Of Health And Human Services and published by Lulu.com. This book was released on 2020-09-06 with total page 128 pages. Available in PDF, EPUB and Kindle. Book excerpt: These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

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 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 Optimizing Widely Reported Hospital Quality and Safety Grades written by Armin Schubert and published by Springer Nature. This book was released on 2022-07-26 with total page 411 pages. Available in PDF, EPUB and Kindle. Book excerpt: This practical, engaging book provides concise, real life-tested guidance to healthcare teams concerned with widely reported and incentivized hospital quality and safety metrics, offering both a conceptual approach and specific advice and frameworks for reviewing quality and safety numerator events, from the perspective and experience of clinicians and administrators working within the Ochsner Health System. The text opens with the rationale for closely managing widely (including publicly) reported hospital patient quality and safety measures. Attention is given to the financial implications of quality performance, with respect to both penalties and payment incentives used by payer organizations. It then reviews the major public ratings and their relevant methodologies, including CMS, AHRQ and NSHN. In addition, it addresses ratings by proprietary organizations that have a large member clientele, such as Vizient, USNews, Leapfrog, Healthgrades, CareChex and others. Each metric - for example, the AHRQ Patient Safety Indicators (PSIs), and other metrics such as readmission rate, risk adjusted complications, hospital-acquired conditions and mortality - is addressed in a stand-alone chapter. For each, the importance, approach to review, opportunity for optimization, and engagement of healthcare staff are reviewed and discussed. Overall, this book forefronts the benefits of a collaborative approach within a health system. The concurrent review process, multidisciplinary collaboration among quality improvement, clinical documentation, coding and medical staff personnel are all emphasized. Also described in detail is the approach to and specific opportunities for medical staff education and engagement. Additional key topics include Engagement of the Medical Staff and House Staff (i.e., residents and other trainees), Futile Care, Surgical Quality Improvement (NSQIP), Nursing Provider Partnership, and Translation of Data Review to Successful Performance Improvement. Specialty chapters on pediatric, neurologic and transplant quality metrics are also included.

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 Step By Step Medical Coding 2017 Edition written by Carol J. Buck and published by . This book was released on 2016-12-06 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Resource ordered for the Health Information Technology program 105301.

Download or read book DRG Expert written by Ingenix and published by . This book was released on 2010-09 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: THE DRG EXPERT has been a trusted and comprehensive reference to the DRG classification system for over 25 years. Organized by major diagnostic category (MDC), the convenient and innovative book layout follows the logical MS-DRG decision process. This is a must-have reference for those who need to verify DRG information and accurately assign MS-DRGs concurrently or retrospectively.

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 Implementing CDISC Using SAS written by Chris Holland and published by SAS Institute. This book was released on 2019-05-30 with total page 294 pages. Available in PDF, EPUB and Kindle. Book excerpt: For decades researchers and programmers have used SAS to analyze, summarize, and report clinical trial data. Now Chris Holland and Jack Shostak have updated their popular Implementing CDISC Using SAS, the first comprehensive book on applying clinical research data and metadata to the Clinical Data Interchange Standards Consortium (CDISC) standards. Implementing CDISC Using SAS: An End-to-End Guide, Revised Second Edition, is an all-inclusive guide on how to implement and analyze the Study Data Tabulation Model (SDTM) and the Analysis Data Model (ADaM) data and prepare clinical trial data for regulatory submission. Updated to reflect the 2017 FDA mandate for adherence to CDISC standards, this new edition covers creating and using metadata, developing conversion specifications, implementing and validating SDTM and ADaM data, determining solutions for legacy data conversions, and preparing data for regulatory submission. The book covers products such as Base SAS, SAS Clinical Data Integration, and the SAS Clinical Standards Toolkit, as well as JMP Clinical. Topics included in this edition include an implementation of the Define-XML 2.0 standard, new SDTM domains, validation with Pinnacle 21 software, event narratives in JMP Clinical, STDM and ADAM metadata spreadsheets, and of course new versions of SAS and JMP software. The second edition was revised to add the latest C-Codes from the most recent release as well as update the make_define macro that accompanies this book in order to add the capability to handle C-Codes. The metadata spreadsheets were updated accordingly. Any manager or user of clinical trial data in this day and age is likely to benefit from knowing how to either put data into a CDISC standard or analyzing and finding data once it is in a CDISC format. If you are one such person--a data manager, clinical and/or statistical programmer, biostatistician, or even a clinician--then this book is for you.

Download or read book Keeping Patients Safe written by Institute of Medicine and published by National Academies Press. This book was released on 2004-03-27 with total page 485 pages. Available in PDF, EPUB and Kindle. Book excerpt: Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.

Download or read book ICD 9 CM Official Guidelines for Coding and Reporting written by and published by . This book was released on 1991 with total page 76 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Download or read book Documentation for Health Records written by Cheryl Gregg Fahrenholz and published by . This book was released on 2013-01-01 with total page 744 pages. Available in PDF, EPUB and Kindle. Book excerpt: