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Internal Medicine/General Practioners – Clinical Documentation Improvement

Course Details

The Internal Medicine 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 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. Know the definition of Principal, secondary, First Listed Diagnosis and uncertain Diagnostic Terms in the context of coding guidelines
  4. Understand the ICD-10-CM Coding overview & guidelines
  5. Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
    1. Abdominal Pain
    2. Acute Coronary Syndrome
    3. Acute, Chronic, Trauma and Neoplasm related pain
    4. Appendicitis
    5. Appendicitis
    6. Arrythmias
    7. Asthma
    8. Bronchitis
    9. Burns
    10. Cerebral Infarction
    11. Cerebrovascular Disorders
    12. Chest pain
    13. Chronic Kidney Disease
    14. CVA & Sequalae
    15. Diabetes
    16. Fever
    17. Gastroenteritis
    18. Gastrointestinal Hemorrhage
    19. Head Injury
    20. Heart Failure
    21. Hernia
    22. Hypertension
    23. Influenza
    24. Malnutrition
    25. Myocardial infarction
    26. Otitis Media
    27. Pneumonia and Pneumonitis
    28. Reaction to Medication – Poisoning vs. Adverse Reaction
    29. Respiratory Failure
    30. Skin ulcer
    31. Sprains, Strains & Dislocations
    32. Tonsillitis
    33. Urinary Tract Infection
  6. Be familiar with Common Internal Procedures & Coding guidelines
  7. Know the Common severity drivers
  8. Assess the Case Studies

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