Program Objectives:

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

• Identify coding and diagnostic components essential for supporting high quality clinical documentation and coding
• Explain the Anesthesiology Clinical Documentation Requirements
• Delve into the Clinical Indicators & Coding Overview
• Evaluate Anesthesia documentation and calculations – DHA & DOH

Program Objectives

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

• Understand the importance of CDI and the Diagnosis Specificity impact on the patient’s quality of care
• Differentiate between clinical and diagnostic terms
• Understand ICD-10-AM Coding overview and guidelines
• Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  • • Acute coronary syndrome
    • Arrhythmia and conduction disorders 
    • Angina 
    • Aneurysm
    • Atherosclerosis 
    • Cardiac arrest
    • Cardiorenal syndrome 
    • Chest pain
    • Cor pulmonale
    • Deep Vein Thrombosis (DVT) 
    • Endocarditis 
    • Heart failure
    • Hypertension
    • Myocardial infarctions 
    • Pericarditis
    • Pulmonary edema
    • Pulmonary embolism
    • Shock 
    • Valvular disorders 
• Be familiar with common cardiovascular procedures and coding guidelines
• Understand ICD-10-AM Documentation Requirements for the Procedures
• Know the common severity drivers
• Understand the examples of IR-DRG and CDI impact on severity of illness, risk of mortality, length of stay, resource weight and reimbursements
• Assess the case studies

Program Objectives

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

• Insurance Protocols
• Common Documentation Tips
• Clinical and diagnostic terms
• Obesity and BMI
• Malnutrition
• Common ICD-10 and ACHI and CCHI-BS Codes
• DOH Coding Guidelines on BMI
• Coverage Criteria and scope of service
• Assigning the BMI as Diagnosis
• CDI Impact on the Reimbursements and Claim Rejections
• Daman Adjudication Rule for Obesity and Morbid Obesity Management

Program Objectives

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

• Importance of Nurse Documentation in CDI
• Common gaps or errors in nursing documentation
• Common conditions related to nursing documentation and assessment and their impact on patient quality of care
• Common procedures related to nursing documentation
• Active wound care management and dressing change Rules
• Case studies

Program Objectives

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

• Differentiate between CDT and USCLS Dental classification
• Assess the coding and diagnostic perspectives when identifying high quality clinical documentation.
• Number the tooth systems
• Have an overview of insurance eligibility criteria coverage and payment and coding rules
• Understand dental services and specific guidelines
• Provide examples of common dental codes rejections

Program Objectives

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

• Understand the importance of CDI and Diagnosis Specificity Impact on the patient’s quality of care
• Differentiate between clinical and diagnostic terms
• Understand ICD-10-AM conventions, standards and clinical guidelines
• Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  • • Abscess, carbuncle and furuncle
    • Acne
    • Cellulitis
    • Dermatitis and eczema
    • Neoplasm (benign and malignant)
    • Psoriasis and parapsoriasis
    • Pemphigoid
    • Pressure ulcers
    • Skin lesions (pre-malignant, benign and malignant)
    • Stasis dermatitis and ulcers
    • Sarcoidosis, scleroderma and systemic lupus erythematous (SLE)
    • Scars
• Be familiar with common dermatology procedures and coding guidelines
• Understand the impact of secondary diagnosis on SOI, ROM and reimbursements
• Know common severity drivers
• Assess case studies

Program Objectives

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

• Understand the importance of CDI and Diagnosis Specificity Impact on a patient’s quality care
• Differentiate between clinical and diagnostic terms
• Understand ICD-10-AM Coding overview and guidelines
• Assess coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  • • Appendicitis
    • Blood loss anemia
    • Cardiac arrest
    • Diabetes
    • Gastrointestinal hemorrhage
    • Heart failure 
    • Hepatic failure
    • Hernia
    • Injury of spleen
    • Injury to internal organs
    • Malnutrition
    • Neoplasm of skin
    • Obesity
    • Pancreatitis
    • Pulmonary edema
    • Renal failure
    • Respiratory failure
    • Sepsis, severe sepsis and septic shock
    • Shock
    • Skin ulcers 
    • Ventilator support
• Be familiar with common general surgery procedures and coding guidelines
• Understand the impact of secondary diagnosis on SOI, ROM and reimbursements
• Be familiar with the reasons for physician queries and their impact on the patient’s quality of care
• Know common severity drivers
• Understand the impact of CDI and query on SOI, ROM, ALOS and DRG weight using case studies
• Assess case studies

Program Objectives

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

• Understand the importance of CDI and Diagnosis Specificity Impact on the patient’s quality of care
• Differentiate between clinical and diagnostic terms
• Know the definition of principal, secondary, first listed diagnosis and uncertain diagnostic terms in the context of coding guidelines
• Understand ICD-10-AM Coding overview and guidelines
• Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  • • Abdominal pain
    • Acute coronary syndrome
    • Acute, chronic, trauma and neoplasm related pain
    • Appendicitis
    • Appendicitis
    • Arrythmias
    • Asthma
    • Bronchitis
    • Burns
    • Cerebral infarction
    • Cerebrovascular disorders
    • Chest pain
    • Chronic kidney disease
    • CVA and sequalae
    • Diabetes
    • Fever
    • Gastroenteritis
    • Gastrointestinal hemorrhage
    • Head injury
    • Heart failure
    • Hernia
    • Hypertension
    • Influenza
    • Malnutrition
    • Myocardial infarction
    • Otitis media
    • Pneumonia and pneumonitis
    • Reaction to medication (poisoning or adverse reaction)
    • Respiratory failure
    • Skin ulcer
    • Sprains, strains and dislocations
    • Tonsillitis
    • Urinary tract infection (UTI)
• Be familiar with common internal procedures and coding guidelines
• Know common severity drivers
• Assess case studies

Program Objectives

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

• Gain an understanding of the impact of CDI and Diagnosis Specificity on the patient’s quality of care
• Differentiate between clinical and diagnostic terms
• Familiarize oneself with the ICD-10-AM official coding guidelines
• Develop the ability to assess coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  • • Abnormal findings during antenatal screening of mother
    • Abruptio placentae
    • Anemia in chronic disease
    • Blood loss anemia
    • Complications associated with abortion
    • Diabetes in pregnancy
    • Drug underdosing
    • Eclampsia
    • Excessive and frequent menstruation
    • Excessive vomiting in pregnancy
    • Female genital prolapses
    • Fetal effects affecting management of pregnancy
    • Fistula
    • Gestational edema
    • Group B streptococcus
    • Gynecological neoplasm
    • Hypertension
    • Infections of genitourinary tract
    • Infections of genitourinary tract in pregnancy
    • Maternal case as the reason for abortion
    • Multiple gestation
    • Normal and cesarean delivery encounter
    • Obesity
    • Obstructed labor
    • Perineal laceration
    • Perineal lacerations
    • Placenta previa
    • Pre-eclampsia
    • Pre-existing or pregnancy-induced conditions
    • Spontaneous abortions
    • Supervision of routine and high-risk prenatal visits
    • Umbilical cord complications
• Be familiar with common obstetrics and gynecology procedures and coding guidelines
• Understand ICD-10-AM documentation requirements for procedures
• Know common severity drivers
• Understand examples of IR-DRG and CDI impact on severity of illness, risk of mortality, length of stay, resource weight and reimbursements
• Understand the principles of ICD-10-AM coding related to obstetrics and non-obstetrics chapters
• Understand the coding overview and sequencing of ICD-10-AM codes as per official coding guidelines:
  • • Chapter 13: Diseases of the musculoskeletal system
    • Chapter 14: Diseases of the genitourinary system
    • Chapter 15: Pregnancy, childbirth and puerperium
    • Chapter 18: Signs and symptoms
    • Chapter 19: Injuries and poisoning
    • Chapter 20: External causes
    • Chapter 21: Factors influencing health status and contact with health services
• Assess case studies

Program Objectives

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

• Gain an understanding of the impact of CDI and Diagnosis Specificity on the patient’s quality of care
• Differentiate between clinical and diagnostic terms
• Familiarize oneself with the ICD-10-AM official coding guidelines
• Develop the ability to assess coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  • • Amputation status
    • Back pain
    • Blood loss anemia
    • Bursitis
    • Compression fractures
    • Disc disorders
    • Hungry bone syndrome
    • Intraoperative and postprocedural complications
    • Joint replacement status
    • Kyphosis and lordosis
    • Myelopathy
    • Musculoskeletal system complications
    • Neoplasms
    • Osteoporosis
    • Osteomyelitis
    • Osteoarthritis
    • Pathological fractures
    • Radiculopathy
    • Rhabdomyolysis
    • Reaction to medication
    • Stress fractures
    • Sprains, strains and dislocations
    • Systemic lupus erythematosus (SLE)
    • Spondylosis
    • Spinal stenosis
    • Traumatic fractures 
    • Wegener’s granulomatosis
• Be familiar with common musculoskeletal procedures and coding guidelines
• Understand ICD-10-AM documentation requirements for the procedures
• Know common severity drivers
• Assess case studies

Program Objectives 

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

• Gain an understanding of the impact of CDI and Diagnosis Specificity on the patient’s quality of care
• Differentiate between clinical and diagnostic terms
• Familiarize oneself with the ICD-10-AM official coding guidelines
• Develop the ability to assess coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  • • Cholesteatoma
    • Cellulitis and lymphangitis of face
    • Conductive and sensorineural hearing loss
    • Eustachian
    • Influenza
    • Mastoiditis
    • Meniere’s disease
    • Neoplasm (Neoplasm of oral cavity)
    • Otitis media
    • Pharyngitis
    • Rhinitis
    • Sinusitis
    • Sleep disordered breathing
    • Tonsillitis
    • Traumatic fractures
    • Tube disorders
• Understand the ICD-10 requirements for procedures
• Know common ear, nose and throat procedures documentation and coding guidelines
• Know common severity drivers 
• Assess case studies

Program Objectives

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

• Gain an understanding of the impact of CDI and Diagnosis Specificity on the patient’s quality of care
• Differentiate between clinical and diagnostic terms
• Familiarize oneself with the ICD-10-AM official coding guidelines
• Develop the ability to assess coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  
  • • Asthma
    • Abdominal pain
    • Bronchitis
    • Burns
    • Birth weight logic in IR-DRG reporting
    • Constipation
    • Congenital anomalies
    • Diabetes
    • Epilepsy
    • Feeding problems
    • Fever
    • Gastroenteritis
    • Hernia
    • Influenza
    • Kidney failure
    • Lymphoma
    • Leukemia
    • Malnutrition
    • Neonatal jaundice 
    • Omphalitis 
    • Otitis media
    • Pneumonia and pneumonitis
    • Respiratory distress syndrome
    • Sepsis
    • Skin ulcer
    • Urinary tract infection
    • Umbilical hemorrhage
• Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in Neonatal Intensive Care Unit (NICU) in the following conditions:
  • • Abnormalities of maturity and growth
    • Retinopathy of Pre-maturity (ROP)
    • Respiratory Disorders
    • Birth Trauma
    • Hematology and Bleeding Disorders
    • Invasive infections
    • Viral infections
    • Metabolic Disorders
    • CNS
    • Cardiac and Circulatory Disorders
    • Hemolysis and Immunization
• Be familiar with common pediatrics and NICU procedures and coding guidelines
• Understand ICD-10-AM documentation requirements for the procedures
• Know the common severity drivers
• Understand the examples of IR-DRG and CDI impact on severity of illness, risk of mortality, length of stay, resource weight and reimbursements
• Assess case studies

Program Objectives

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

• Identify coding and diagnostic elements that should be identified to support high quality clinical documentation and coding
• Understand Emergency Medicine & Critical Care – Clinical Documentation and the Diagnosis Specificity impact on the patient quality care 
• Understand Clinical Indicators and Coding Overview
• Know the Impact of Documentation
• Know the Common severity indicators
• Understand Secondary diagnoses (CC/MCC) * impact on the severity of illness, risk of mortality and reimbursements
• Know when to query
• Assess case studies with IR-DRG Impact

* CC-Comorbid conditions: *MCC-Major Comorbidity /Complication

Program Objectives

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

• Identify coding and diagnostic elements that should be identified to support high quality clinical documentation and coding
• Understand endocrinology and its disorders – Clinical Documentation and the Diagnosis Specificity impact on the patient quality care
• Understand Clinical Indicators and Coding Overview
• Know the impact of documentation
• Know the common severity indicators
• Understand secondary diagnoses (CC/MCC) * impact on the severity of illness, risk of mortality and reimbursements
• Know when to query
• Assess case studies with IR-DRG Impact

* CC-Comorbid conditions: *MCC-Major Comorbidity /Complication

Program Objectives

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

• Identify coding and diagnostic elements that should be identified to support high quality clinical documentation and coding
• Understand gastroenterology and its disorders – Clinical Documentation and the diagnosis specificity impact on the Patient quality care
• Understand the Clinical Indicators and Coding Overview
• Know the impact of documentation
• Know the common severity indicators
• Understand secondary diagnoses (CC/MCC) * impact on the severity of illness, risk of mortality and reimbursements
• Know when to query
• Assess case studies with IR-DRG Impact

* CC-Comorbid conditions: *MCC-Major Comorbidity /Complication

Program Objectives

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

• Identify coding and diagnostic elements that should be identified to support high quality clinical documentation and coding
• Understand Hematology and oncology and its disorders – Clinical Documentation and the Diagnosis Specificity impact on the Patient quality care
• Understand the Clinical Indicators and Coding Overview
• Know the impact of documentation
• Know the common severity indicators
• Understand secondary diagnoses (CC/MCC) * impact on the severity of illness, risk of mortality and reimbursements
• Know when to query
• Assess case studies with IR-DRG Impact

* CC-Comorbid conditions: *MCC-Major Comorbidity /Complication

Program Objectives

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

• Identify coding and diagnostic elements that should be identified to support high quality clinical documentation and coding
• Clinical and diagnostic terms
• Essentials for laboratory and pathology report
• Understand laboratory and pathology and its disorders – Clinical documentation and the diagnosis specificity impact on the patient quality care, including:
  • • Labs Coding Tips
    • Organ or Disease Oriented Panels
    • Evocative and suppression testing
    • Drug Testing
    • Molecular Pathology
    • Chemistry
    • Hematology and Coagulation
    • Immunology
    • Microbiology
    • Cytopathology and Surgical Pathology
    • HAAD- Common Observation values
    • DHA – Common Observation values
    • Case Studies
    • Common Lab Rejections
    • Shafafiya Requirement for claim submission for labs

Program Objectives

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

• Understand importance of CDI and the Diagnosis Specificity impact on the patient quality of care
• Differentiate between clinical and diagnostic terms
• Understand ICD-10-AM Coding overview and guidelines
• Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  • • Acute Ischemic Stroke
    • Altered Mental Status (AMS)
    • Alzheimer’s Disease
    • Cerebral edema and brain compression
    • Cerebrovascular Disorders
    • Coma
    • Concussion
    • Degenerative Nervous System Disorders
    • Delirium
    • Dementia
    • Depression
    • Diabetic Neuropathy
    • Encephalopathy
    • Glasgow coma and NIHSS scale
    • Head Injury
    • Intracranial Hemorrhage, subarachnoid and Intracerebral hemorrhage
    • Intraoperative and Postoperative Strokes
    • Meningitis
    • Non-Traumatic subdural and Extradural Hemorrhage
    • Parkinson’s Disease
    • Polyneuropathy
    • Seizure and Epilepsy
    • Sequelae of Cerebrovascular disorders
    • Spinal Disorders
    • Spinal cord injury and Spinal column conditions
    • Traumatic Brain Hemorrhage
    • Transient ischemic attack (TIA)
• Understand the ICD-10 Requirements for Procedures
• Know the common spinal and nerve procedures, documentation and coding guidelines
• Understand the examples of IR-DRG and CDI Impact on severity of illness, risk of mortality, length of stay, resource weight and reimbursements
• Know the common severity drivers
• Assess case studies

Program Objectives

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

• Understand importance of CDI and the Diagnosis Specificity impact on the patient quality care
• Differentiate between clinical and diagnostic terms
• Understand ICD-10-AM Coding overview and guidelines
• Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  • • Astigmatism
    • Cataract
    • Corneal ulcers
    • Conjunctivitis
    • Diabetic Retinopathy
    • Exophthalmos
    • Enophthalmos
    • Glaucoma
    • Inflammation of orbit
    • Mechanical complication of ocular Prosthetic device
    • Myopia and Hypermetropia
    • Retinal detachments and breaks
    • Retinal Vascular occlusions
    • Scleritis
• Know the common severity drivers
• Understand the Examples of AR-DRG and CDI Impact on severity of illness, risk of mortality, length of stay, resource weight and reimbursements

Program Objectives

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

• Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in few conditions
• Explain the Basics in Billing and coding an Eye exam
• Understand the Regulation of Optometry services
• Describe the Common Ophthalmology Services
• Discuss the Extended Ophthalmoscopy Reporting Guidelines

Program Objectives

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

• Evaluate both the coding and diagnostic perspectives to identify high quality clinical documentation for the following conditions.
  
  • • Sprains, Strains and dislocations
    • Disruption of anterior cruciate ligaments
    • Joint Pain
    • Bicipital Synovitis and Tenosynovitis
    • Shoulder dislocation
    • Knee Meniscal Tear
    • SLAP Lesion -Shoulder
    • Disc Disorders
    • Myelopathy
    • Osteoporosis
    • Radiculopathy
    • Spinal stenosis
• Know Insurance Eligibility Criteria Coverage overview
• Understand cast, splint and strapping guidelines
• Know insurance payment and coding rules
• Know PT evaluation and re-evaluation codes
• Understand supervised modalities
• Define therapeutic and constant attendance procedures
• Assess timed minutes and chart
• Know modalities and treatment time range
• Understand timed reporting scenarios
• Know ICD-10-AM guidelines
• Know fracture care and ER reporting guidelines
• Clarifying the reporting of splints and cast applications by non-physicians
• Assess PT case studies

Program Objectives

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

• Evaluate both the coding and diagnostic perspectives to identify high quality clinical documentation for the following conditions.
  
  • • Schizophrenic Disorder
    • Bipolar Disorder
    • Major Depressive Disorder
    • Depression
    • Adjustive Disorder
    • Types of Anxiety
    • Altered Mental Status
    • Dementia
    • Delirium
    • Hallucinations
    • Eating Disorder
    • Sleeping Disorder
    • Impulsive Control
• Differentiate between Clinical and Diagnostic Terms
• Know the insurance payment and coding rules
• Know common psychiatric services and specific guidelines
• ICD-10-AM Guidelines for Mental, Behavioral and Neurodevelopment disorders (F01 – F99)

Program Objectives

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

• Evaluate both the coding and diagnostic perspectives to identify high quality clinical documentation for the following conditions.
  
  • • Schizophrenic Disorder
    • Bipolar Disorder
    • Major Depressive Disorder
    • Depression
    • Adjustive Disorder
    • Types of Anxiety
    • Altered Mental Status
    • Dementia
    • Delirium
    • Hallucinations
    • Eating Disorder
    • Sleeping Disorder
    • Impulsive Control
• Know Insurance Eligibility Criteria Coverage overview
• Differentiate between Clinical and Diagnosis Terms
• Know the insurance Payment & coding Rules
• Know Psychiatric services & Specific Guidelines
• GAHS Guidelines for Controlled Medications
• ICD-10-AM Guidelines for Mental, Behavioral and Neurodevelopment disorders (F01 – F99)
• Daman Adjudication Rule for Psychiatry Billing

Program Objectives

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

• Evaluate both the coding and diagnostic perspectives to identify high quality clinical documentation
• Distinguishing between clinical and diagnostic terminology
• Understand the essential components of Radiology report
• Understand Radiology and its disorders – Clinical documentation and the diagnosis specificity impact on the patient quality care, including:
  • • Importance of Medical Documentation
    • Clinical Indications
    • Plain Films
    • Contrast Procedures
    • 3D Rendering
    • Combination services
    • LDCT
    • Breast Imaging
    • Nuclear Medicine
    • PET
    • Ultrasound
    • Duplex Imaging
    • NIPS
    • Vascular IR
    • Diagnostic Imaging
    • CVC Access
    • Non vascular IR
    • Moderate sedation
    • Multiple Physicians

Program Objectives

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

• Identify coding and diagnostic elements that should be identified to support high quality clinical documentation and coding
• Understand Nephrology and its disorders – Clinical Documentation and the Diagnosis Specificity impact on the Patient quality care
• Understand the Clinical Indicators and Coding Overview
• Know the Impact of Documentation
• Know the common severity indicators
• Know when to query

Program Objectives

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

• Identify coding and diagnostic elements that should be identified to support high quality clinical documentation and coding
• Understand Respiratory system and its disorders – Clinical Documentation and the Diagnosis Specificity impact on the Patient quality care
• Understand the Clinical Indicators and Coding Overview
• Know the Impact of Documentation
• Understand Secondary diagnoses (CC/MCC) * impact on the severity of illness, risk of mortality, length of stay, resource weight and reimbursements
• Know when to query
• Assess case studies with IR-DRG Impact

* CC-Comorbid conditions: *MCC-Major Comorbidity/Complication

Program Objectives

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

• Understand importance of Clinical Documentation improvement and the Diagnosis Specificity impact on the patient quality care
• Differentiate between clinical and diagnostic terms
• Understand ICD-10-AM Coding overview and guidelines
• Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  • • Abdominal Pain
    • UTI
    • Cystitis
    • BPH
    • Urethral stricture
    • Vesicoureteral Reflux
    • Male erectile dysfunction
    • Neurogenic bladder
    • Pyelonephritis
    • Urosepsis
    • Sepsis and SIRS
    • Neoplasm
    • Acute Kidney Failure
    • Chronic Kidney Disease
    • Nephritis Syndrome
    • Urolithiasis
    • Anemia
    • Diabetes
• Be familiar with common urology procedures and coding guidelines
• Common severity drivers
• Examples of common insurance rejections

Program Objectives

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

• Understand anatomy for vascular coding
• Review the rules for vascular procedures
• Review ICD-10 future coding
• Understand documentation on Vascular Notes
• Code co-existing conditions: when is it appropriate and why is it important?
• Code common vascular disorders: atherosclerosis of native and grafted arteries, aneurysms, arterial dissections, venous disorders and more
• Code non-pressure ulcers; new clinical concepts and how to document
• Code vascular injuries: applying and understanding the: 7th character (A, D, S). 
• Assess the coding and diagnostic perspectives when identifying high quality clinical documentation in the following conditions:
  • • Aneurysm
    • Atherosclerosis
    • Thrombosis and Thrombophlebitis of Veins of Extremities
    • Pulmonary Embolism
    • Saddle embolism
    • Varicose Veins
    • Vascular ulcers
    • Deep Vein Thrombosis (DVT)
    • Diabetes
    • Diabetic foot ulcer
    • Stasis ulcers
• Common Cardiovascular Therapeutic Service and Procedures- Coding and Documentation guidelines
• Interventional cardiology coding guidelines
• Assess the case studies