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The Principles of Clinical Documentation Improvement

Course Details

The  Principles of  Clinical documentation improvement is a guide to understand the importance of clinical documentation specificity & diagnostic terms. It will help in understanding the common Documentation & Coding issues, Pillars of high quality documentation, how the healthcare data is standardized & how the hospitals receive, the optimal maximal reimbursements with Compliance and Quality care of the patient. Understand the common CDI Areas and the impact within the specialty (ies) & reasons for Physicians queries with the case studies.

Learning Objectives

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

1. Understand the definition and importance of the Clinical Documentation Improvements
2. Know how the CDI helps in standardizing the healthcare Data and maximizing the optimal reimbursements for the hospitals
3. Differentiate between Clinical and Diagnostic Terms
4. Know the Top Coding and Billing Errors
5. Understand the Clinical Documentation improvement Goals
6. Know the pillars for high quality documentation
7. Know the definition of Principal, secondary, First Listed Diagnosis and uncertain Diagnostic Terms in the context of coding guidelines

8. Understand the common CDI Areas and the impact, below are some examples:

-Orthopedics
-Gastroenterology
-Pulmonology
-Understanding Injections and infusions
-Dermatology
-Obstetrics & Gynecology
-Functional endoscopic sinus surgeries
-Neurospinal Surgeries
-Nursing and other Non-Treating Physicians

9. Be familiar with the reasons for Physician Queries and Compliant Queries

10. Understand the CDI and Query impact on SOI,ROM,ALOS and DRG weight – Case study



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