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First Steps in Outpatient CDI: Tips and Tools for Building a Program Anny P. Yuen, RHIA, CCS, CCDS, CDIP Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO Find best practices and helpful advice for getting started in outpatient CDI with First Steps in Outpatient CDI: Tips and Tools for Building a Program. This first-of-its-kind book provides an overview of what outpatient CDI entails, covers industry guidance and standards for outpatient documentation, reviews the duties of outpatient CDI specialists, and examines how to obtain backing from leadership. Accurate documentation is important not just for code assignment, but also for a variety of quality and reimbursement concerns. In the past decade, outpatient visits increased by 44% while hospital visits decreased by nearly 20%, according to the Medicare Payment Advisory Commission. However, just because physicians are outside the hospital walls doesn't mean they're free from documentation challenges. For these reasons, CDI programs are offering their assistance to physician practices, ambulatory surgical centers, and even emergency rooms. This book will explore those opportunities and take a look at how others are expanding their record review efforts in the outpatient world. This book will help you: Target the outpatient settings that offer the greatest CDI opportunities Understand the quality and payment initiatives affecting outpatient services Understand the coding differences between inpatient and outpatient settings Identify data targets Incorporate physician needs to ensure support for program expansion Assess needs by program type
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
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.
Focusing on the essential information you need to know for the most commonly encountered problems in outpatient internal medicine, this practical volume in the Washington Manual® series provides concise, high-yield content that reflects today’s advances in patient evaluation and management. In one convenient, portable resource, you’ll find complete coverage of everything from hypertension and diabetes to sleep disorders, nutrition, and care of the cancer patient—all at your fingertips for quick review and reference. Edited by Drs. Maureen D. Lyons, Peter J. McDonnell, and Jennifer M. Schmidt, The Washington Manual® of Outpatient Internal Medicine, 3rd Edition, is an excellent companion to the Washington Manual® of Medical Therapeutics, which thoroughly covers inpatient care.
The Complete Guide to CDI Management Cheryl Ericson, MS, RN, CCDS, CDIP Stephanie Hawley, RN, BSN, ACM Anny Pang Yuen, RHIA, CCS, CCDS, CDIP Managing a CDI department can be a daunting task for new and seasoned managers alike. The Complete Guide to CDIManagement provides CDI program managers and directors with insight into the most common issues associated with implementing, staffing, running, and growing a CDI department. The book also covers core skills such as auditing and metrics, and it provides strategies for overcoming challenges related to electronic records, changing regulatory landscapes, and resource limitations. The Complete Guide to CDI Management incorporates the deep expertise of multiple authors with varied backgrounds who have come together to share their firsthand knowledge. From reporting structures and productivity measurement to defining a mission and physician engagement, this definitive resource addresses the wide array of issues facing CDI managers and directors in today's hospital environment. Table of Contents About the Authors Introduction Chapter 1: An Introduction to CDI for the New Manager History of Coded Data The Medical Coder The Prospective Payment System Adding "Severity" Into the DRG Methodology CDI Basics Summary Chapter 2: Growing a CDI Department The Traditional Role of CDI CDI Review Population Principal Diagnosis Assignment Types of DRG Reviews Quality Focus Summary Chapter 3: Developing Relationships Sharing the Mission Physician Engagement Obstacles to Developing a Physician Relationship Leveraging Queries as an Educational Tool The Art of Clinical Validation The Query Format Query Templates Fostering a Relationship With Coding Networking Summary Chapter 4: Department Structures and Staffing Expectations Department Structures Staffing/Hiring Physician Advisor Creating a Career Ladder Continuing Education CDI Department Meetings Evaluations Credentialing Initialing vs. Revitalizing Summary Chapter 5: Demonstrating the Return on Investment Measuring Success Productivity and Sample Metrics Summary Chapter 6: Challenges and How to Overcome Them Organization Issues Resource Issues Summary Appendixes Appendix A: Resources
**Selected for Doody's Core Titles® 2024 with "Essential Purchase" designation in Health Information Management** Take your first step toward a successful career in medical coding with guidance from the most trusted name in coding education! The bestselling Buck's Step-by-Step Medical Coding is a practical, easy-to-use resource that shows you exactly how to code using all current coding sets. To reinforce your understanding, practice exercises follow the explanations of each coding concept. In addition to coverage of reimbursement, ICD-10-CM, CPT, HCPCS, and inpatient coding, an Evolve website includes 30-day access to TruCode® Encoder Essentials. No other book so thoroughly covers all coding sets! - Theory and practical review questions (located at the end of each chapter) focus on recalling important chapter information and application of codes. - A step-by-step approach makes it easier to build your coding skills and remember the material. - Learning objective and glossary review questions reinforce your understanding of key chapter concepts and terms - Coverage reflects the latest CPT E/M guidelines changes for office and other outpatient codes. - 30-day trial to TruCode® Encoder Essentials gives you experience with using an encoder (plus access to additional encoder practice exercises on the Evolve website). - UNIQUE! "Real-life" coding reports simulate the reports you will encounter as a coder and help you apply coding principles to actual cases. - Online activities on Evolve provide extra practice with assignments, including coding reports. - More than 450 illustrations help you understand the types of medical conditions and procedures being coded, and include examples taken directly from Elsevier's professional ICD-10 and HCPCS manuals. - UNIQUE! Four coding-question variations — covering both single-code questions and multiple-code questions and scenarios — develop your coding ability and critical thinking skills. - UNIQUE! Coders' Index in the back of the book makes it easy to quickly locate specific codes. - Official Guidelines for Coding and Reporting boxes show the official guidelines wording for inpatient and outpatient coding alongside in-text explanations. - Exercises, Quick Checks, and Toolbox features reinforce coding rules and concepts, and emphasize key information. - Valuable tips and advice are offered in features such as From the Trenches, Coding Shots, Stop!, Caution!, Check This Out, and CMS Rules. - Sample EHR screenshots (in Appendix D) show examples similar to the electronic health records you will encounter in the workplace. - NEW! Coding updates include the latest information available, promoting accurate coding and success on the job.
Take your first step toward a successful career in medical coding with guidance from the most trusted name in coding education! The bestselling Buck's Step-by-Step Medical Coding is a practical, easy-to-use resource that shows you exactly how to code using all current coding sets. To reinforce your understanding, practice exercises follow the explanations of each coding concept. In addition to coverage of reimbursement, ICD-10-CM, CPT, HCPCS, and inpatient coding, an Evolve website includes 30-day access to TruCode® Encoder Essentials. No other book so thoroughly covers all coding sets! - Theory and practical review questions (located at the end of each chapter) focus on recalling important chapter information and application of codes. - A step-by-step approach makes it easier to build your coding skills and remember the material. - Learning objective and glossary review questions reinforce your understanding of key chapter concepts and terms - 30-day trial to TruCode® Encoder Essentials gives you experience with using an encoder (plus access to additional encoder practice exercises on the Evolve website). - UNIQUE! "Real-life" coding reports simulate the reports you will encounter as a coder and help you apply coding principles to actual cases. - Online activities on Evolve provide extra practice with assignments, including coding reports. - Coverage reflects the latest CPT E/M guidelines changes for office and other outpatient codes. - More than 450 illustrations help you understand the types of medical conditions and procedures being coded, and include examples taken directly from Elsevier's professional ICD-10 and HCPCS manuals. - UNIQUE! Four coding-question variations — covering both single-code questions and multiple-code questions and scenarios — develop your coding ability and critical thinking skills. - UNIQUE! Coders' Index in the back of the book makes it easy to quickly locate specific codes. - Official Guidelines for Coding and Reporting boxes show the official guidelines wording for inpatient and outpatient coding alongside in-text explanations. - Exercises, Quick Checks, and Toolbox features reinforce coding rules and concepts, and emphasize key information. - Valuable tips and advice are offered in features such as From the Trenches, Coding Shots, Stop!, Caution!, Check This Out, and CMS Rules. - Sample EHR screenshots (in Appendix D) show examples similar to the electronic health records you will encounter in the workplace. - NEW! Coding updates include the latest information available, promoting accurate coding and success on the job.
These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
Take your first step toward a successful career in medical coding with guidance from the most trusted name in coding education! The bestselling Buck's Step-by-Step Medical Coding is a practical, easy-to-use resource that shows you exactly how to code using all current coding sets. To reinforce your understanding, practice exercises follow the explanations of each coding concept. In addition to coverage of reimbursement, ICD-10-CM, CPT, HCPCS, and inpatient coding, an Evolve website includes 30-day access to TruCode® Encoder Essentials. No other book so thoroughly covers all coding sets! - Theory and practical review questions (located at the end of each chapter) focus on recalling important chapter information and application of codes. - A step-by-step approach makes it easier for students to build coding skills and remember the material. - Learning objective and glossary review questions reinforce student understanding of key chapter concepts and terms. - 30-day trial to TruCode® Encoder Essentials gives students experience with using an encoder (plus access to additional encoder practice exercises on the Evolve website). - UNIQUE! "Real-life" coding reports (cleared of any confidential information) simulate the reports students will encounter as coders, and help them apply coding principles to actual cases. - Online activities on Evolve provide extra practice with assignments, including coding reports. - More than 450 illustrations help in understanding the types of medical conditions and procedures being coded, and include examples taken directly from Elsevier's professional ICD-10 and HCPCS manuals. - UNIQUE! Four coding-question variations — covering both single-code questions and multiple-code questions and scenarios — develop students' coding ability and critical thinking skills. - UNIQUE! Coders' Index in the back of the book makes it easy to quickly locate specific codes. - Official Guidelines for Coding and Reporting boxes show the official guidelines wording for inpatient and outpatient coding alongside in-text explanations. - Exercises, Quick Checks, and Toolbox features reinforce coding rules and concepts, and emphasize key information. - Valuable tips and advice are offered in features such as From the Trenches, Coding Shots, Stop!, Caution!, Check This Out, and CMS Rules. - Sample EHR screenshots (in Appendix D) show examples similar to the electronic health records students will encounter in the workplace. - NEW! Coding updates include the latest information available, promoting accurate coding and success on the job. - NEW! Coverage of CPT E/M Guidelines changes for Office and Other Outpatient codes.