Clinical Documentation Improvement Boot Camp Online
Course Outline
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, Official ICD-9-CM Coding Guidelines and Coding Clinic
- Major Diagnostic Categories (MDC)
- Medical vs. surgical DRGs
- ICD-9-CM codes
- Alpha and numeric indexes
- Selection of principal diagnosis
- Reporting of secondary diagnoses
- Present on admission / hospital-acquired conditions
- Whose documentation counts?
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
Diseases of the Respiratory System (MDC 4)
- Clinical signs and symptoms
- COPD
- Simple pneumonia v. "complex pneumonia"
- Aspiration pneumonia
- Respiratory failure
- Mechanical ventilators
- Other
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
Diseases of the Digestive and Hepatobiliary System (MDCs 6, 7)
- Clinical signs and symptoms
- Esophagitis, gastritis
- GI bleeds
- Blood loss anemia
- Cholecystectomies:
- Open v. laparoscopic
- Common bile duct exploration
Diseases of the Urinary System (MDC 11)
- Clinical signs and symptoms
- Acute and chronic renal failure
- Urosepsis v. UTI
- UTI and sepsis/SIRS related to indwelling catheter
- Diabetic renal failure
- Admission for dialysis
Diseases of the Endocrine System and Nutritional Disorders (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
Diseases of the Neuro System (MDC 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 (MDC 9)
- Clinical signs and symptoms
- Pressure ulcers
- Excisional debridements
Other Diseases
- Clinical signs and symptoms
- HIV disease
- Obesity and BMI
- Anemias
- Myeloproliferative diseases and neoplasms
- Symptoms
Developing Communication Skills with Physicians/Ancillary Staff
- Teaching physicians "what's in it for them"
- CDI and its effect on physician profiles and E/M payments
Reviewing the Medical Record Documentation and Constructing Physician Queries
- What is a query?
- AHIMA practice brief-guidelines for non-leading queries
- Written v. 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, Ethics and Compliance
- RAC program
- How CDI programs can assist with RAC defense
- OIG audits
*Agenda subject to change
Note that all MDC modules discuss relevant Coding Clinic guidelines and/or provide clinical case scenarios, and all other modules are followed by questions to test your comprehension.
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