The Clinical Documentation Improvement Specialist's Handbook, Second Edition
The Clinical Documentation Improvement Specialist's Handbook, Second Edition

Author: Heather Taillon

Publisher: HC Pro, Inc.

Published: 2011-01-21

Total Pages: 171

ISBN-13: 1601467753

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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

The Clinical Documentation Improvement Specialist's Complete Training Guide
The Clinical Documentation Improvement Specialist's Complete Training Guide

Author: Laurie L. Prescott

Publisher:

Published: 2014-10-23

Total Pages: 0

ISBN-13: 9781556452833

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Your new CDI specialist starts in a few weeks. They have the right background to do the job, but need orientation, training, and help understanding the core skills every new CDI needs. Don't spend time creating training materials from scratch. ACDIS' acclaimed CDI Boot Camp instructors have created The Clinical Documentation Improvement Specialist's Complete Training Guide to serve as a bridge between your new CDI specialists' first day on the job and their first effective steps reviewing records. The Clinical Documentation Improvement Specialist's Complete Training Guide is the perfect resource for CDI program managers to help new CDI professionals understand their roles and responsibilities. It will get your staff trained faster and working quicker. This training guide provides: An introduction for managers, with suggestions for training staff and guidance for manual use Sample training timelines Test-your-knowledge questions to reinforce key concepts Case study examples to illustrate essential CDI elements Documentation challenges associated with common diagnoses such as sepsis, pneumonia, and COPD Sample policies and procedures

Guide to Clinical Documentation
Guide to Clinical Documentation

Author: Debra Sullivan

Publisher: F.A. Davis

Published: 2011-12-22

Total Pages: 301

ISBN-13: 0803629974

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Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.

The Clinical Documentation Improvement Specialist's Guide to ICD-10
The Clinical Documentation Improvement Specialist's Guide to ICD-10

Author: Glenn Krauss

Publisher: HC Pro, Inc.

Published: 2011-03

Total Pages: 163

ISBN-13: 1601468172

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Take charge of ICD-10 documentation requirements The implementation of ICD-10 brings with it new documentation requirements that will have a significant impact on the work of your CDI team. The higher degree of specificity of information needed to code accurately will have a direct correlation to reimbursement and compliance. CDI specialists need a firm understanding of the new code set, and the rules that govern it, to obtain the appropriate level of documentation from physicians. The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only book that addresses ICD-10 from the CDI point of view. Written by CDI experts, it explains the new documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. You'll find the specific documentation requirements to appropriately code conditions such as heart failure, sepsis, and COPD. Learn from your peers The Clinical Documentation Improvement Specialist's Guide to ICD-10 includes case studies from two hospitals that have already begun ICD-10 training so you can use their timelines as a blue print to begin your organization's training and implementation. ICD-10 implementation happens in 2013. It's not too soon to start developing the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. Benefits: * Tailored exclusively for CDI specialists * Side-by-side comparison of what documentation is necessary now v. what will be required starting October 1, 2013 * Timelines to train physicians in new documentation requirements to ensure readiness by implementation date * Strategies and best practices to ensure physician buy-in

CDI Companion for Physician Advisors
CDI Companion for Physician Advisors

Author: Trey La Charité

Publisher: Hcpro, a Division of Simplify Compliance

Published: 2016-11

Total Pages: 0

ISBN-13: 9781683081708

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When it comes to clinical documentation, physician advisors have a range of important responsibilities, from query escalation to denials management and everything in between. With all these tasks on their plate, physician advisors are constantly pulled in different directions, making it hard to make the best use of their time. CDI Companion for Physician Advisors: Notes From the Field is designed to help physician advisors structure their time properly and carry out their CDI duties effectively and efficiently. This book will help physician advisors: Find their feet in the CDI role Identify tools to provide effective documentation education for physicians and CDI staff Engage medical staff in documentation improvement efforts Understand common documentation deficiencies for difficult diagnoses such as sepsis, heart failure, and kidney disease Work with their CDI team to tackle advanced record reviews in areas such as quality, audit defense, and outpatient HCCs Figure out how to best structure their time to carry out CDI duties

The Physician Advisor's Guide to Clinical Documentation Improvement
The Physician Advisor's Guide to Clinical Documentation Improvement

Author: Trey La Charité

Publisher:

Published: 2014-04-30

Total Pages: 0

ISBN-13: 9781615693474

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The Physician Advisor's Guide to Clinical Documentation Improvement Physician advisors are not just needed for case management anymore. ICD-10-CM/PCS and the changing landscape of healthcare reimbursement make their input invaluable in the realm of CDI and coding, too. This book will help your physician advisors quickly understand the vital role they play and how they can not only help improve healthcare reimbursement, but also reduce claims denials and improve the quality of care overall. This book will: * Provide job descriptions and sample roles and responsibilities for CDI physician advisors * Outline the importance of CDI efforts in specific relation to the needs and expectations of physicians * Highlight documentation improvement focus areas by Major Diagnostic Category * Review government initiatives and claims denial patterns, providing physician advisors concrete tools to sway physician documentation

Justcoding's Practical Guide to Coding Management
Justcoding's Practical Guide to Coding Management

Author: Rose T. Dunn

Publisher:

Published: 2016-10-01

Total Pages: 150

ISBN-13: 9781683080886

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JustCoding's Practical Guide to Coding Management Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS ICD-10's arrival changed more than code selection--it's also brought challenges related to coder productivity, coding quality and accuracy, staffing shortages, coder education and training, and the increased need for auditing. The old rules and standards for running a department no longer apply, and coding managers must update their efforts, just as coders themselves have. This book gives coding managers new benchmarks, standards, and tips to ensure they're running an effective coding department. It provides strategies for coder retention, best practices to balance internal and outsourced coders, and tips for managing on-site and remote staff. The book also provides much-needed information for managers on how to educate their teams on coding's role within the revenue cycle.

The Physician Advisor's Guide to Clinical Documentation Integrity, Second Edition
The Physician Advisor's Guide to Clinical Documentation Integrity, Second Edition

Author: Trey La Charité

Publisher:

Published: 2020-08

Total Pages: 212

ISBN-13: 9781645350224

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Physician advisors are not just needed for case management anymore. ICD-10-CM/PCS and the changing landscape of healthcare reimbursement make their input invaluable in the realm of CDI and coding, too. This book will help your physician advisors quickly understand the vital role they play and how they can not only help improve healthcare reimbursement but also reduce claims denials and improve the quality of care overall.

Quality Medical Editing for the Healthcare Documentation Specialist
Quality Medical Editing for the Healthcare Documentation Specialist

Author: Patricia Ireland

Publisher:

Published: 2015-03-20

Total Pages: 0

ISBN-13: 9781285187068

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Ideal for classroom use, individual study, or professional training, QUALITY MEDICAL EDITING FOR THE HEALTHCARE DOCUMENTATION SPECIALIST, First Edition, is a timely, unique text designed to teach and reinforce essential skills for medical editors. Comprehensive in scope, this practical guide explains the differences between medical editing and traditional transcription; how to use technology, word expander programs, and computer accessories effectively; and ways to improve accuracy--including developing excellent listening skills and the ability to correctly decipher accents, identify medications, and distinguish soundalikes. The authors have also provided a variety of sample reports--including more than 200 medical reports and their corresponding dictation audio files. Reports span numerous specialties and document types, creating extensive opportunities to learn the medical editing process, practice formatting and editing, and become familiar with common errors produced by speech recognition. The text also features extensive information on professional development, continuing education, and earning credentials, as well as useful tips on gaining experience, finding employment, and advancing one's career. Abundant teaching and learning features--such as material on grammar and punctuation, review activities, critical-thinking exercises, and several appendices with key references and resources--make this text even more valuable for current and aspiring medical editors seeking career success.

Clinical Documentation Improvement (CDI) Made Easy, 2nd Edition
Clinical Documentation Improvement (CDI) Made Easy, 2nd Edition

Author: Anthony Nkwuaku

Publisher: Createspace Independent Publishing Platform

Published: 2018-02-24

Total Pages: 264

ISBN-13: 9781984238788

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The book provides clear guides on how to perform the vital duties required in obtaining accurate, quality, complete, and specific documentation from the providers so as to reflect the quality of care, severity of illness and risk of mortality of admitted patients during their encounter to the hospital or inpatient rehab. The book is a "must have" for every CDIS or anyone involved in clinical documentation. The book has current ICD-10-CM/PCS update with pertinent information on the 2018 Official Coding Guidelines for Coding and Reporting, Coding Clinic advice, Pay for Performance, sample queries, various disease processes by MDCs, CDI strategy for success in inpatient rehab, rehab impairment group codes and categories, list of all the surgical and MS-DRGs, and much more. Remember, if it was not documented and documented accurately, it never happened.