Clinical Documentation Improvement Boot Camp
Course Outline
Day 1
Overview of Clinical Documentation Improvement (CDI)
- What is CDI?
- Who is the clinical documentation specialist (CDS)?
- What is the role of the CDS?
Inpatient Prospective Payment System and MS-DRGs
- Overview of the Medicare system
- What is an MS-DRG?
- How is the DRG assigned?
- Principal diagnosis
- Complications/comorbidities (CCs) and major CCs
- Principal procedure
- Case-mix index (CMI)
- Relative weight
- Blended rate
- How is CMI calculated?
- Why does CMI matter?
Getting to Know DRG Expert and the ICD-9-CM Manual
- Major Diagnostic Categories (MDC)
- Medical vs. surgical DRGs
- ICD-9-CM codes
- Alpha and numeric indexes
Official ICD-9-CM Coding Guidelines and
Coding Clinic
- Selection of principal diagnosis
- Reporting of secondary diagnoses
- Present on admission / hospital-acquired conditions
- Whose documentation counts?
- Sample exercises
Focused Physiology/Pharmacology/Disease Processes
- Infectious diseases (MDC 18)
- Clinical signs and symptoms
- SIRS/sepsis/severe sepsis/septic shock
- Postoperative and posttraumatic infections
- Fever of unknown origin
- Other
- Coding Clinic guidelines
- Clinical case scenarios
- Diseases of the respiratory system (MDC 4)
- Clinical signs and symptoms
- COPD
- Simple pneumonia vs. “complex pneumonia”
- Aspiration pneumonia
- Respiratory failure
- Mechanical ventilators
- Other
- Coding Clinic guidelines
- Clinical case scenario
Day 2
Diseases of the Cardiovascular System (MDC 5)
- Clinical signs and symptoms
- Chest pain/Angina/CAD
- Congestive heart failure
- Acute myocardial infarction
- Cardiac catheterizations
- PTCA and other cardiac procedures
- Coding Clinic guidelines
- Clinical case scenarios
Diseases of the Digestive and Hepatobiliary
System (MDCs 6, 7)
- Clinical signs and symptoms
- Esophagitis, gastritis
- GI bleeds
- Blood loss anemia
- Cholecystectomies:
- Open vs. laparoscopic
- Common bile duct exploration
- Coding Clinic guidelines
- Clinical case scenarios
Diseases of Urinary System (MCD 11)
- Clinical signs and symptoms
- Acute and chronic renal failure
- Urosepsis vs. UTI
- UTI and sepsis/SIRS related to indwelling catheter
- Diabetic renal failure
- Admission for dialysis
- Coding Clinic guidelines
- Clinical case scenarios
Diseases of the Endocrine System (MDC 10)
- Clinical signs and symptoms
- DM Type I and II
- Complications of DM
- Dehydration and malnutrition
- Electrolyte imbalances
- Common CC’s in this MDC
- Amputations
- Endocrine Dx
- Coding Clinic guidelines
- Clinical case scenarios
Day 3
Diseases of the Neuro System (MCD 1)
- Clinical signs and symptoms
- TIA vs. CVA
- Seizures vs. epilepsy
- Diabetic manifestations
- Carotid artery procedures
- Coding Clinic guidelines
- Clinical case scenarios
Diseases of the Skin (MCD 9)
- Clinical signs and symptoms
- Pressure ulcers
- Excisional debridements
- Coding Clinic guidelines
- Clinical case scenarios
Other Diseases
- Clinical signs and symptoms
- HIV disease
- Obesity and BMI
- Anemias
- Myeloproliferative diseases and neoplasms
- Symptoms
- Coding Clinic guidelines
- Clinical case scenarios
Developing Communication Skills with
Physicians/Ancillary Staff
- Teaching physicians “what’s in it for them”
- CDI and its effect on physician profiles/
E/M payment
Day 4
Reviewing the Medical Record Documentation
and Constructing Physician Queries
- What is a query?
- AHIMA practice brief–guidelines for
non-leading queries
- Written vs. verbal query processes
- Concurrent vs. retrospective queries
- Use of standardized query templates
and clinical indicators
- How to track query response
Measuring the Success of a CDI Program
- What to measure–analysis and objectives
- CMI vs. performance
- Severity of illness/risk of mortality
- Performance tracking and trending your
performance by
- Program
- Physician
- Hospital department
- CDI specialist
- Professionalism
- RAC program
- How CDI programs can assist with RAC defense
- OIG audits
- Case examples and questions
Agenda subject to change.
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