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Tuesday, September 19, 9:00 AM - 10:00 AM, MT

GS1 / Incorporating CDI Into Any Audit / Panel

Join our panel of esteemed industry professionals, auditors, and clinical documentation improvement (CDI) experts for an engaging discussion focused on the integration of CDI into auditing practices. The panel will explore the benefits, challenges, and best practices of incorporating CDI into the auditing workflow, sharing their expertise, real-world experiences, and success stories from organizations that have successfully implemented CDI initiatives. Accurate clinical documentation plays a pivotal role in ensuring quality care, proper reimbursement, and compliance. CDI offers a strategic approach to enhance the accuracy and completeness of clinical documentation, ultimately improving the integrity of audit processes.

Tuesday, September 19, 10:15 AM - 11:30 AM, MT

1A / CDI for GI: Hernia Coding – No Heavy Lifting Required / Kelly Shew

As you’ve probably heard by now, hernia repair codes got some big updates this year! This session will start with a review of all of the hernia codes and the information needed to properly code them. We will discuss the new guidelines, including measuring hernia lengths, for the new codes. Finally, we will review several chart notes and identify areas for documentation improvement.

1B / With or Without Documentation Challenges / Rhonda Buckholtz

We all were aware of the guideline changes with the implementation of ICD-10-CM but the impact was not yet known. We are going to take a deep dive into the “with or without” guideline in ICD-10-CM and determine how you can lead documentation efforts that will protect compliance and revenue. In this session you will learn how involved the guideline is and where technology fails you, how it impacts physician documentation, how the coding could be negatively effecting your revenue and tips on improving documentation.

Tuesday, September 19, 12:30 PM - 1:45 PM, MT

2A / The Importance of Documenting SDOH / Marianne Durling

This session will review SDOH, what it is and why it is so important in today's healthcare landscape. Learn how it impacts patient care, as well as current and future reimbursement. We will review the tools and barriers to properly collect and utilize SDOH data.

2B / CDI and E/M Clinical Significance of the Medical Record AND Value of Documenting Co-Morbid Conditions/Risks /Jaci Kipreos

The AMA documentation guidelines provide a generous definition to “Problems Addressed” and still we often do not find that all conditions addressed have been reported. Why is that? Clinical Documentation Improvement (CDI) is not just for risk adjustment purposes. This concept applies to creating a complete medical record of that patient encounter. The principles of CDI can be applied to every E/M encounter, and we want to discuss why those principles should be applied to all E/M documentation. We will discuss the importance and review some examples.

Tuesday, September 19, 2:15 PM - 3:30 PM, MT

3A / Compliant Provider Queries / Melissa Kirshner

AHIMA and ACDIS released an update to the Provider Compliant Query Guidelines in 2022. In this session, we will review these recent updates to the provider query process and discuss applying them to day-to-day processes.

3B / Operationalize Your Outpatient CDI Program / Leonta Williams

A CDI Program should be a system-wide process that includes collaboration between many cross-departmental teams. Now that CDI has gained momentum in the outpatient setting, it is important for leaders to establish proper policies and protocols that will support the program and result in the desired ROI.  To establish an effective CDI program, leaders should propose a budget or evaluate current budgets to determine the proper amount of staffing, type of staffing, and technology required.  Set a vision or mission statement for your CDI program.  Determine what type of conditions, services, programs, etc. that your CDI program will review.  Establish goals for your program along with processes that help evaluate KPIs at different steps in the program.  A good audit program within your CDI program is integral to ensure coders and clinical documentation specialists are adhering to both coding and documentation guidelines, but also your internal policies.  Your CDI workflow process should not be ambiguous. There should be clear communication around CDI metrics, medical record review, query process/rate, provider education, escalation policies, etc. Join us for this session as we discuss best practices to operationalize, evaluate, and sustain your outpatient CDI program.

Tuesday, September 19, 4:00 PM - 5:15 PM, MT

4A / Complexities of Remote Monitoring / Raemarie Jimenez


4B / Coding Cerebrovascular Events Based on Pathophysiology / Nancy Reading

This session will take a deep dive into the brain and the different etiologies of cerebrovascular accidents.  ICD 10 CM code and ICD 10 PCS code selection is based on the type of lesion and its location in the brain. The attendee will come away with a better understanding of brain anatomy, physiology, and pathophysiology.  Coding rules and conventions for coding CVAs and sequelae will be covered. Bring your questions to this interactive session!

Wednesday, September 20, 9:00 AM - 10:15 AM, MT

GS2 / How Does the Non-clinical Person Become a Clinical CDI Coder/Auditor / Panel

This panel discussion will focus on exploring the journey of non-clinical professionals who aspire to become clinical documentation improvement (CDI) coders/auditors. This informative session aims to shed light on the challenges, opportunities, and strategies involved in transitioning from a non-clinical background to a clinical role within the CDI field. Don’t miss this panel if you are a non-clinical professional looking to embark on a career path in clinical CDI or seeking to expand your knowledge and opportunities within the field. Gain valuable insights, learn from industry experts, and be inspired by success stories of individuals who have successfully made the leap from a non-clinical position to a clinical CDI coder/auditor role.

Wednesday, September 20, 10:30 AM - 11:45 AM, MT

5A / Leveraging AI to Enhance the CDI Process / Jacob Swartzwelder

This session will focus on how Artificial/Augmented Intelligence (AI) can improve the Clinical Documentation Improvement (CDI) process. The goal of CDI is to ensure that provider documentation accurately reflects the care provided, resulting in precise coding, accurate reimbursement, and better patient outcomes. AI technologies like Natural Language Processing (NLP) and machine learning algorithms can assist in identifying documentation gaps, potential coding errors, and areas for improvement in provider documentation.  We will discuss practical applications of AI in CDI, as well as ethical, legal, and implementation considerations.  Attendees will learn how AI can streamline the documentation review process and provide actionable insights for providers to improve documentation quality, resulting in better patient outcomes.

5B / Pathophysiology - Cancers of the Lung, Breast and Colon / Leonta Williams

Cancer remains the second most common cause of death in the U.S.  As coders and CDI specialists we should understand the prevalence of cancer and how varying cancer types are diagnosed.  In this session, we will focus on cancers of the lung, breast, and colon.  We’ll discuss hereditary and environmental factors associated with these cancers as well as identify common signs and symptoms. An ongoing challenge for providers is documenting the acuity at the time of encounter, so we will investigate the differences between active cancer and cancer in history status.  Another challenge for providers is accurately documenting secondary cancers, so we will also review common metastatic sites and code selection of primary vs. secondary sites.

Wednesday, September 20, 1:15 PM - 02:30 PM, MT

6A / Documentation Guidelines for E/M / Jaci Kipreos

The golden rule forever has been that services must be documented in order to support that the service had been performed. The AMA documentation guidelines have posed some challenges for coders, auditors and providers. What is reliable information to use when working through these definitions? Where are we still debating the gray areas? Why is it so hard to explain risk…and what does that mean anyway? How do we all get on the same page…or do we? This session will delve into some of the challenges and discuss reliable resources and helpful ways to convey the information to providers. If documentation is the key to success, we must find a way to dissect a medical record and be on the same page as the provider. Let’s talk about that!

6B / Pathophysiology – Cardiology / Sharon Oliver

Heart disease is among the top killer in the United States. Heart disease does not care about age or gender. We are impacted by heart condition whether we are born with it (congenital) or developed due to lifestyle (acquired). This presentation will address the top recorded diagnoses pertaining to heart disease, and how that respective disease, when first diagnosed, progresses. What steps can be taken by the plan of care and the patient's participation in compliance with the provider to correct the condition. How other organ systems can be impacted will also be addressed.

Wednesday, September 20, 3:00 PM - 04:15 PM, MT

7A / COVID Long Haulers / Samuel Church


7B / Whoops, You Missed a Spot! Uncovering the Top Documentation Bloopers and Auditor Wish Lists / Heather Greene

Join us for an informative journey as we dive deep into the world of Mental Health documentation! In this presentation, we'll open the vault of auditors' secrets by revealing: The top missed documentation/audit issues; Possible solutions to documentation concerns; An "Auditors' Wish List" where we share their tips to improve documentation. Get ready to learn as we navigate the world of mental health documentation, transforming common pitfalls into steppingstones towards mastery!

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