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Author :
Publisher :
ISBN 13 : 9781622547517
Total Pages : pages
Book Rating : 4.5/5 (475 download)
Download or read book Guide to Clinical Validation and Documentation Improvement for Coding written by and published by . This book was released on 2021-12-21 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
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Publisher :
ISBN 13 : 9781622546350
Total Pages : 0 pages
Book Rating : 4.5/5 (463 download)
Download or read book Guide to Clinical Validation and Documentation Improvement for Coding written by and published by . This book was released on 2020 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt:
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Publisher :
ISBN 13 : 9781622546367
Total Pages : pages
Book Rating : 4.5/5 (463 download)
Download or read book Guide to Clinical Validation, Documentation and Coding 2021 written by and published by . This book was released on 2020-12 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
Author : AAPC
Publisher : AAPC
ISBN 13 : 1626889791
Total Pages : 13 pages
Book Rating : 4.6/5 (268 download)
Download or read book Clinical Documentation Reference Guide - First Edition written by AAPC and published by AAPC. This book was released on 2020-03-12 with total page 13 pages. Available in PDF, EPUB and Kindle. Book excerpt: It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.
Author : Optum360
Publisher :
ISBN 13 : 9781601519924
Total Pages : 0 pages
Book Rating : 4.5/5 (199 download)
Download or read book Guide to Clinical Validation Documentation and Coding 2014 written by Optum360 and published by . This book was released on 2013-09 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: The 2014 Guide to Clinical Validation, Documentation and Coding provides the clinical criteria necessary for code assignment. This resource describes the clinical documentation needed for determining if the condition is a complication, or when a medical condition should be coded as an additional diagnosis. Now coders, utilization review staff, and HIM managers can systematically evaluate the clinical criteria that influence code assignments and patient care. Covers 50 of the most challenging inpatient medical diagnoses and procedures. Provides detailed clinical criteria and physician documentation requirements. Code assignment justifications are thoroughly outlined. Helps craft physician queries. Learn how to address fine distinctions in a patient's medical condition and ensure appropriate reimbursement. Provides a detailed clinical description of problematic diagnoses or procedures--from a coder's perspective--plus the clinical criteria that support code assignment. Assists coders in determining what clinical elements are necessary for initial diagnosis code assignment, when it should be coded as a complication, and when the condition should be coded as an additional diagnosis. Ties in to ICD-10-PCS. Identifies other terminology that would qualify for the ICD-10-PCS specific root operation term.
Author : Heather Taillon
Publisher : HC Pro, Inc.
ISBN 13 : 1601467753
Total Pages : 171 pages
Book Rating : 4.6/5 (14 download)
Download or read book The Clinical Documentation Improvement Specialist's Handbook, Second Edition written by Heather Taillon and published by HC Pro, Inc.. This book was released on 2011-01-21 with total page 171 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Clinical Documentation Improvement Specialist's Handbook, Second Edition Marion Kruse, MBA, RN; Heather Taillon, RHIA, CCDS Get the guidance you need to make your CDI program the best there is... The Clinical Documentation Improvement Specialist's Handbook, Second Edition, is an all-inclusive reference to help readers implement a comprehensive clinical documentation improvement (CDI) program with in-depth information on all the essential responsibilities of the CDI specialist. This edition helps CDI professionals incorporate the latest industry guidance and professional best practices to enhance their programs. Co-authors Heather Taillon, RHIA, and Marion Kruse, MBA, RN, combine their CDI and coding expertise to explain the intricacies of CDI program development and outline the structure of a comprehensive, multi-disciplinary program. In this edition you will learn how to: Adhere to the latest government and regulatory initiatives as they relate to documentation integrity Prepare for successful ICD-10 transition by analyzing your CDI program Step up physician buy-in with the improved education techniques Incorporate the latest physician query guidance from the American Health Information Management Association (AHIMA) Table of Contents Chapter 1: Building the CDI Program Chapter 2: CDI and the healthcare system Chapter 3: Application of coding guidelines Chapter 4: Compliant physician queries Chapter 5: Providing physician education Chapter 6: Monitoring the CDI program What's new in the Second Edition? Analysis of new industry guidance, including: AHIMA's "Managing an Effective Query Process" and "Guidance for Clinical Documentation Improvement Programs." CMS guidance from new IPPS regulations, MLN Matters articles, Quality Improvement Organizations, and the Recovery Audit Contractor (RAC) program, among others Strategies to help you incorporate the guidance into your CDI program. Tools to help you interpret MAC initiatives and RAC focus areas to enhance your CDI program and help prevent audit takebacks New sample queries, forms, tools, and industry survey data BONUS TOOLS! This book also includes bonus online tools you can put to use immediately! Sample query forms Sample job descriptions for CDI managers, and CDI specialists Sample evaluation form for CDI staff Sample pocket guide of common documentation standards
Author :
Publisher :
ISBN 13 : 9781622544066
Total Pages : 0 pages
Book Rating : 4.5/5 (44 download)
Download or read book Guide to Clinical Validation, Documentation and Coding 2019 written by and published by . This book was released on 2019 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Resource added for the Health Information Technology program 105301.
Author :
Publisher :
ISBN 13 : 9781622541706
Total Pages : 0 pages
Book Rating : 4.5/5 (417 download)
Download or read book Guide to Clinical Validation, Documentation and Coding 2016 written by and published by . This book was released on 2015 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Author : Anneleah Williams Bridges
Publisher :
ISBN 13 :
Total Pages : 102 pages
Book Rating : 4.6/5 (54 download)
Download or read book Bridging the Gap Between Coding and Clinical Documentation Improvement (CDI) written by Anneleah Williams Bridges and published by . This book was released on 2020-02-14 with total page 102 pages. Available in PDF, EPUB and Kindle. Book excerpt: Physicians play vital roles in the overall quality of patient care. However, HIM professionals and clinical documentation improvement specialists also share essential roles in the healthcare system as guardians of PHI and advocates for continuity of care through consistent documentation and accurate code assignment. Clinical documentation improvement specialists (CDIS) are responsible for the communicative aspects of the process, often serving as a liaison between the provider and the coder. The CDIS ensures that the medical record is complete, there is clinical validation to support diagnoses, and that the medical record is consistent without conflicting or obscure documentation. HIM professionals share some of the responsibility of CDIS in addition to abstracting data from the medical record and assigning the appropriate codes to accurately report the patient's clinical picture.Without the two teams working hand in hand to improve the medical record's documentation, billing errors could ensue, and the quality of patient care is at risk. The process is very detailed and requires a clinical and coding mind to work efficiently. More organizations are calling for their CDIS to learn the fundamentals of coding and for their coders to review the medical record with clinical eyes. Which is whythisresource proves invaluable! Whether you're already skilled in HIM but want to add CDI expertise to your resume, or an existing CDIS looking to update your coding skillset this publication will be of good use to you!
Author : Rn Phn Nkwuaku, Msn Cphq
Publisher : Createspace Independent Publishing Platform
ISBN 13 : 9781519538185
Total Pages : 246 pages
Book Rating : 4.5/5 (381 download)
Download or read book Clinical Documentation Improvement written by Rn Phn Nkwuaku, Msn Cphq and published by Createspace Independent Publishing Platform. This book was released on 2015-12-17 with total page 246 pages. Available in PDF, EPUB and Kindle. Book excerpt: Clinical Documentation Improvement (CDI) Made Easy is a great resource and reference that every Clinical Documentation Improvement Specialist/Professional (CDIS/CDIP), coder, physician champion/advisor, and others involved in the CDI must have. The book is a compendium of sound clinical knowledge and experience, clinical documentation expertise, and quality, which will help the CDIS/CDIP and others maximize their potentials in performing their core duties. Whether you are a new CDIS trying to learn CDI or an experienced CDIS hoping to stay current with CDI world, or involved in the CDI, this book will be very valuable to you. Remember, accurate and quality documentation is a reflection of great patient care. "If it wasn't documented, and documented accurately, it never happened." This book clearly explained various query opportunities by Major Disease Classifications (MDCs) with some sample queries. It defines and analyses different disease processes, creates CDIS awareness and what to look for under various MDCs, ICD-10-CM/PCS, explained current CMS Pay for Performance (P4P), and the CDI responsibility under P4P, explained some pertinent coding guidelines, 2016 Official Coding Guidelines for Coding and Reporting, AHIMA/ACDIS practice brief for queries and compliance, and much more. I have no doubt in my mind that this book is a concise but a comprehensive tool and reference that anyone involved in CDI should always have at his/her side. The Author Anthony O Nkwuaku, RN, PHN, MSN, CPHQ, CCDS is very knowledgeable and experienced as a clinician, clinical instructor, and Clinical Documentation Improvement Specialist.
Author :
Publisher :
ISBN 13 : 9781622541362
Total Pages : 0 pages
Book Rating : 4.5/5 (413 download)
Download or read book Guide to Clinical Validation, Documentation and Coding 2015 written by and published by . This book was released on 2014 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Author :
Publisher : Optuminsight
ISBN 13 : 9781622546350
Total Pages : 0 pages
Book Rating : 4.5/5 (463 download)
Download or read book Guide to Clinical Validation, Documentation and Coding 2020 written by and published by Optuminsight. This book was released on 2019-12 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Author : Cheryl Ericson
Publisher :
ISBN 13 : 9781683088400
Total Pages : 164 pages
Book Rating : 4.0/5 (884 download)
Download or read book Clinical Validation Reviews for CDI Professionals written by Cheryl Ericson and published by . This book was released on 2019-03 with total page 164 pages. Available in PDF, EPUB and Kindle. Book excerpt: Clinical Validation Reviews for CDI Professionals tackles the nuances of a critical concern for CDI professionals and provides expert guidance for meeting challenging chart reviews head-on. With government auditors frequently denying claims due to lack of clinical indicators for documented diagnoses, CDI professionals are left asking whether they should simply code a clinically unsupported diagnosis or query the physician. While the answer may seem clear, querying can lead to productivity reductions, additional education outreach, and a call for broader policies governing query escalation and reconciliation. This brand-new book leverages its authors' expertise to help CDI professionals effectively and efficiently navigate these issues during a necessary query process. By understanding clinical validation concerns, CDI staff can become better translators and storytellers--clarifying the medical record without appearing to question the physician's medical judgment.
Author :
Publisher :
ISBN 13 : 9781622546404
Total Pages : pages
Book Rating : 4.5/5 (464 download)
Download or read book Clinical Documentation Improvement Desk Reference for ICD-10-CM & Procedural Coding written by and published by . This book was released on 2020-11 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
Author : Sharon Easterling
Publisher : Ahima Press
ISBN 13 : 9781584264576
Total Pages : 139 pages
Book Rating : 4.2/5 (645 download)
Download or read book Certified Documentation Improvement Practitioner (CDIP) Exam Preparation written by Sharon Easterling and published by Ahima Press. This book was released on 2016 with total page 139 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Author :
Publisher :
ISBN 13 : 9781622547593
Total Pages : pages
Book Rating : 4.5/5 (475 download)
Download or read book Clinical Documentation Improvement Desk Ref for ICD-10-CM & Procedure Coding written by and published by . This book was released on 2021-11 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
Author : Saravanan Kannapiran
Publisher :
ISBN 13 : 9781077329355
Total Pages : 37 pages
Book Rating : 4.3/5 (293 download)
Download or read book The Clinical Documentation Improvement (CDI) Specialist's Guide to Obstetrics Coding written by Saravanan Kannapiran and published by . This book was released on 2019-07 with total page 37 pages. Available in PDF, EPUB and Kindle. Book excerpt: This slim book is designed to be a concise instructional manual on how to properly code the most common cases one sees daily on the obstetrics ("ob") floor as a Clinical Documentation Improvement (CDI) specialist. There is no "fluff" here. I know you are a busy professional and I wanted to give you the most important information so you don't waste your time. Follow the methodology outlined here and you will maximize the SOI, Weight, and Revenue of the cases you code. Note however that this book is not for the seasoned CDI specialist already familiar with coding the ob floor; you probably already know most of the information presented here. Also, this book is not meant as a reference manual on ob coding; it is a guide for the CDI Specialist, not the Coder.
