Course Provider
Learning Objectives
• Explain the goals and objectives of a clinical documentation improvement (CDI) department and the role of the CDI specialist (CDIS)
• Describe what population of records to review, how often to review them, and when a review is complete
• Demonstrate an understanding of Medicare’s inpatient prospective payment system (IPPS) and how it relates to the role of the CDIS
• Demonstrate an understanding of how specific and accurate provider documentation affects hospital reimbursement through the assignment of a principal diagnosis, secondary diagnoses, and coded data
• Discuss general ICD-10-CM coding guidelines and apply these guidelines when assigning the principal diagnosis and secondary diagnoses as part of the MS-DRG assignment process
• Discuss the significance of Coding Clinic for ICD‐10‐CM guidance when assigning and sequencing codes, and applying its guidance to documentation and query scenarios
• Develop techniques for detailed medical record review in order to identify incomplete, vague, and/or missing diagnoses based on clinical indicators within the medical record
• Discuss physician education strategies related to the impact of improved documentation on hospital reimbursement and individual physician profiles
• Develop compliant physician query techniques based on industry standards and best practices
• Describe professional ethics associated with the CDI role as related to compliance initiatives, including those monitored by Recovery Auditors and the Office of Inspector General (OIG)