Students will learn principles of clinical documentation improvement. In addition, there will be discussion of benefits of clinical documentation improvement (CDI) programs, documentation requirements, quality measures, payment methodologies, and clinical conditions including common signs and symptoms, typical treatment, documentation tips and coding concepts. This course is recommended for anyone who is preparing for a career in clinical documentation improvement and strongly recommended for anyone who is preparing for AAPC’s Certified Documentation Expert-Outpatient (CDEO) certification examination.

Course Objectives:

• Define benefits of clinical documentation improvement programs
• Explain the impact of the OIG Work Plan and Corporate Integrity Agreements (CIAs)
• Define the proper use of queries and effective provider communication.
• Identify National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) risk areas
• Explain the HIPAA privacy rule, including details on protected health information, minimum necessary,sharing of information, and enforcement
• Identify medical record documentation standards and record retention standards
• Identify common errors found in documentation for evaluation and management, minor surgery,radiology, pathology and laboratory, and medicine services
• Explain aggregate analysis and when it is useful
• Explain the importance of discussing audit findings with the provider
• Provide practical application of auditing operative reports and evaluation and management services