Clinical Documentation Improvement

Overview:

For many coders, the single greatest hindrance to their coding accuracy is the quality of documentation – including the degree of specificity, consistency, completeness, and timeliness.

Clinical Documentation Improvement (CDI) is the future of auditing. As reporting requirements and regulations are increased, technology evolves, and with ICD-10 on the horizon, it's becoming increasingly crucial for coders to work with physicians to improve documentation today so they can protect their practice tomorrow.

You Will Learn:

• The complete clinical documentation review process
• Essential steps to accurately code diagnoses and procedures, even in ICD-10
• How to reduce exposure to RAC and other audits
• Necessary habits of accurate and comprehensive documentation
• The crucial elements of claim-supporting documentation
• Steps to implement a CDI plan in your office
• Tips on how to effectively communicate the documentation process to your physician

This workshop will walk you through several case examples (like this one) to expose the most common errors that plague practices and result in frequent denials and increases compliance risks. Leaving this workshop, you will be armed with knowledge to provide your clinic with protection and improve the overall revenue using tools already available to you.