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General Surgery -Clinical Documentation Improvement

 

Course Details

The General surgery course is a guide to understand the importance of clinical documentation specificity & diagnostic terms and the impact on the patient Quality of care, It will helps in understanding the common documentation & Coding issues, Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in specific conditions/Disease(s), Common  ICD-10-CM & Common CPT coding overviews in light of the official Coding guidelines. Understand the CDI and Query impact on patient  SOI,ROM,ALOS and DRG weight along with Case studies.

Learning Objectives

By the end of this module, you should be able to:

  1. Understand importance of Clinical Documentation improvement and the Diagnosis Specificity impact on the Patient Quality care
  2. Differentiate between Clinical Vs Diagnostic Terms
  3. Understand the ICD-10-CM Coding overview & guidelines
  4. Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
    1. Appendicitis
    2. Blood Loss Anemia
    3. Cardiac arrest
    4. Diabetes
    5. Gastrointestinal Hemorrhage
    6. Heart Failure
    7. Hepatic Failure
    8. Hernia
    9. Injury of Spleen
    10. Injury to internal Organs
    11. Malnutrition
    12. Neoplasm of Skin
    13. Obesity
    14. Pancreatitis
    15. Pulmonary edema
    16. Renal Failure
    17. Respiratory Failure
    18. Sepsis, Severe sepsis and septic shock
    19. Shock
    20. Skin Ulcers
    21. Ventilator support
  5. Be familiar with Common General Surgery Procedures & Coding guidelines
  6. Understand the Impact of secondary Diagnosis on SOI,ROM & Reimbursements
  7. Be familiar with the reasons for Physician Queries and it’s impact on patient Quality care
  8. Know the Common severity drivers
  9. Understand the CDI and Query impact on SOI,ROM,ALOS and DRG weight – Case study
  10. Assess the Case Studies

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