CDI & DRG Training

Clinical Documentation Improvement (CDI) Training

Many claims denials are due to improper Clinical Documentation, if the Claims Department is not trained on CDI, how are they able to access that the claim should be in a Denial Status due to Clinical Documentation without the proper Training and Certification?

Implementing a Clinical Documentation Improvement (CDI) Program can significantly improve a healthcare facility’s financial health.

Beyond the immediate benefit of ensuring accurate reimbursement so as to claim for the amount which is owed, CDI programs play a crucial role in protecting facilities against the risks associated with improper documentation, such as regulatory penalties and payer audits!

The implementation of CDI programs in inpatient facilities represents a multifaceted approach to revenue enhancement, risk management, and quality improvement. Our CDI experts possess a comprehensive understanding of not only Medical Coding and Billing practices but also the regulations governing healthcare fraud, abuse, and compliance. This includes staying abreast of updates and revisions to Clinical Documentation updates and any new Mandates from governing bodies, Country to Country.

Our CDI programs aligns closely with the evolving requirements of payers, whether Government or Commercial Insurance Payers and TPAs. By ensuring documentation reflects the severity of illness and intensity of care provided, CDI efforts contribute to accurate representation of patient acuity, which is essential for appropriate reimbursement within the Diagnosis Related Group (DRG) payment system.

Within the DRG framework, the assignment of codes and documentation of comorbidities and complications (CC/MCC) directly impact reimbursement rates. CDI specialists play a pivotal role in identifying and documenting these conditions accurately to maximize reimbursement while maintaining compliance with payer guidelines.

CDI TRAINING COURSE MODULES 

• Module 1:Origins of CDI

• Module 2:Clinician’s View of CDI

• Module 3:Reasons to Implement CDI

• Module 4:Cloning and Conflicting Documentation

• Module 5:Supporting Documentation for Reporting Procedures and Services

• Module 6:

• How Official Coding Guidelines Influence Documentation
• Introduction to Clinical Documentation Improvement (CDI)
• Historical perspective on the evolution of CDI in healthcare
• Key milestones and developments in CDI
• Understanding the clinician’s role in documentation improvement
• Collaboration between clinicians and CDI specialists
• Addressing challenges and concerns from the clinician’s perspective
• Identifying the need for CDI
• Improving patient care through accurate documentation
• Regulatory and compliance considerations
• Recognizing and addressing issues related to cloning.
• Strategies to manage conflicting documentation.
• Impact on coding and reimbursement
• Importance of comprehensive documentation for procedures
• Guidelines for supporting documentation in coding.
• Ensuring accuracy in procedure code assignment
• Overview of official coding guidelines relevant to your specialty
• Adherence to coding guidelines for accurate code assignment
• Case studies illustrating the impact of coding guidelines on documentation

• Module 7:POA (Present on Admission)

• Module 8:Primary and Secondary Diagnosis

• Module 9:Medical Necessity and Clinical Validation

• Module 10:Assessment and Patient History

• Module 11:Specific Code Capture

• Module 12: Implementation of Your Documentation Improvement Program

• Module 13: Query Program Sustainability

• Module 14: CDI Success Metrics

• Module 15: Technology in CDI

• Understanding the significance of POA indicators
• Incorporating POA documentation in cases
• Impact on coding and reporting
• Differentiating between primary and secondary diagnoses
• Ensuring proper sequencing and specificity in diagnosis documentation
• Implications for coding and reimbursement
• Defining medical necessity in documentation
• Strategies for clinical validation of diagnoses and procedures
• Ensuring alignment with payer requirements

• Comprehensive assessment documentation
• Importance of capturing relevant patient history
• Impact on coding and quality reporting

• Detailed exploration of system-specific codes
• Documentation requirements for specific procedures
• Case studies for hands-on learning

• Steps for implementing a successful CDI program
• Role of stakeholders in program implementation
• Overcoming common implementation challenges

• Strategies for sustaining a successful query program
• Continuous education and training for CDI staff
• Monitoring and adapting to changes in documentation practices.

• Key performance indicators for measuring CDI success.
• Establishing benchmarks and goals for improvement
• Continuous monitoring and reporting of success metrics.

• Leveraging technology for efficient CDI processes
• Electronic health records (EHR) and CDI integration
• Tools and software for enhancing documentation accuracy.

• Module 16: CDI Brings Many Improvements

• Module 17: Elements of a Strong Clinical Documentation Program

• Module 18: Setting Goals

• Module 19: Documentation and Reimbursement

• Module 20: Cardiac-Specific Documentation Issues

• Module 21: Aligning with Quality Measures