Clinical Documentation Improvement Boot Camp

Clinical Documentation Improvement Boot Camp® (BLR) S

Clinical Documentation Improvement Boot Camp®


Course Overview

Launch a successful CDI career with help from the experts at ACDIS.

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The CDI Boot Camp is ACDIS’ premier training for CDI specialists. Trusted by hundreds of CDI specialists as the go-to source for CDI education, this course defines the role of CDI specialists and provides comprehensive training on their responsibilities.
Improve your CDI know-how with ACDIS-endorsed best practices for medical record review and compliant physician querying. Learn the ins and outs of Medicare’s IPPS methodology and how it relates to short-term acute care hospital reimbursement, which is often a focus of CDI efforts. Specifically, participants learn about MS-DRG methodology, including how MS-DRGs are assigned and how documentation affects code assignment and sequencing.
A majority of the Boot Camp is dedicated to exploring diagnoses typically in need of clarification for proper code assignment and MS-DRG assignment. Armed with this knowledge, CDI specialists can credibly query physicians to ensure accurate claims data and reimbursement.

Leave the CDI Boot Camp with a complete understanding of:
The ICD-10-CM Official Guidelines for Coding and Reporting, as seen from a CDI perspective
Diagnoses frequently in need of additional documentation to support accurate code assignment across all major body systems
The value of querying the provider for clarification and best practices associated with the query process
Tips for educating physicians on the basics of hospital reimbursement under IPPS and the value of complete documentation on organizational and professional profiling
IPPS methodology based on MS-DRG assignment and the impact of diagnosis assignment and sequencing on hospital reimbursement
CDI benchmarking basics, compliance risks, and professional ethics

The CDI Boot Camp will help you:
Implement a step-by-step process for thorough medical record review based on industry guidelines
Develop compliant verbal and written physician queries and understand how to effectively query providers
Recognize the important clinical indicators for problematic diagnoses such as heart failure, sepsis, acute renal failure, and encephalopathy
Understand the impact of compliance initiatives on CDI, including the Recovery Auditor program and the Office of Inspector General Work Plan

CDI Boot Camp—see the difference for yourself!
Check out all the benefits of this HCPro Boot Camp:

Custom-designed course materials: Course materials are developed by an adult education expert. The curriculum uses a “how to” approach where participants learn how to apply CDI concepts that they can then customize to their organizational needs. Content is regularly updated based on changing industry practices and participant feedback.
Live instruction: Classes are taught by an experienced instructor who is credentialed as a CDI professional and works as an industry subject matter expert for ACDIS.
Small class size: We limit the number of course participants in order to maintain a low participant-teacher ratio. This allows us to provide individual instruction as needed when participants find a topic particularly challenging; it also allows time for discussion.
Well-established program: Brought to you by the Association of Clinical Documentation Improvement Specialists (ACDIS), this Boot Camp from the industry’s only dedicated CDI association provides the best-in-class education you expect.

Clinical Documentation Improvement Boot Camp®
Learning Objectives
At the conclusion of the course, participants will be able to:
Explain the goals and objectives of a CDI department and the role of the CDI specialist (CDIS)
Describe what population of records to review, how often to review them, and when a review is complete
Demonstrate an understanding of Medicare’s IPPS and how it relates to the role of the CDIS
Demonstrate an understanding of how specific and accurate provider documentation affects hospital reimbursement through the assignment of a principal diagnosis, secondary diagnoses, and coded data
Discuss general ICD-10-CM coding guidelines and apply these guidelines when assigning the principal diagnosis and secondary diagnoses as part of the MS-DRG assignment process
Discuss the significance of Coding Clinic for ICD-10-CM guidance when assigning and sequencing codes, and applying its guidance to documentation and query scenarios
Develop techniques for detailed medical record review in order to identify incomplete, vague, and/or missing diagnoses based on clinical indicators within the medical record
Discuss physician education strategies related to the impact of improved documentation on hospital reimbursement and individual physician profiles
Develop compliant physician query techniques based on industry standards and best practices
Describe professional ethics associated with the CDI role as related to compliance initiatives, including those monitored by Recovery Auditors and the OIG
Discuss and apply basic metrics that support the success and/or progress of a CDI department, individual CDISs, and participating physicians

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Clinical Documentation Improvement Boot Camp®
Course Outline/Agenda

Day One

Healthcare Data and the Health Record

UHDDS definitions
The attending provider
Common elements of the health record

Medicare and Medicaid

Overview of the Medicare system
Key terminology
Medicare Part A
– Inpatient hospital care
– Overview of quality initiatives
Medicare Part B
– Outpatient/observation hospital care
Introduction to Medicaid

Diagnosis Codes and Sequencing

Diagnosis coding in ICD-10-CM
Coding conventions
Official coding guidelines
Principal diagnosis guidelines in ICD-10-CM
Selection of principal diagnosis
Reporting of secondary diagnoses
Present on admission

Introduction to Procedure Code Sets

Procedure coding
– Coding conventions
– Official coding guidelines
– The characters of PCS

Day Two

The Inpatient Prospective Payment System (IPPS) and MS-DRGs

How is a DRG assigned?
Impact of the principal diagnosis
Major Diagnostic Categories (MDCs)
Impact of complications/comorbidities (CCs) and major CCs (MCCs)
Impact of procedures
Determining hospital reimbursement

Record Review and Queries

Reviewing medical record documentation
What is a query?
Justification to issue a query
How to construct a query
– Written vs. verbal processes
– Concurrent vs. retrospective
– Available formats
The importance of clinical indicators

Getting to Know DRG Expert (ICD-10-CM)

Major Diagnostic Categories (MDC)
Medical vs. surgical MS-DRGs
Alpha and numeric indexes
Sample exercises

Key Infectious Diseases and Complications

Coding guidelines and key Coding Clinic references
Infectious disease process
Identification of the causative organism
SIRS/sepsis/severe sepsis/septic shock
HIV disease
Complications of care

Day Three

Key Diseases Associated With Injuries, the Musculoskeletal System, and the Skin

Coding guidelines and key Coding Clinic references
Episode of care (7th character)
Poisoning, adverse effects, and underdosing
Excisional debridement

Key Diseases of the Respiratory System

Coding guidelines and key Coding Clinic references
Chronic respiratory conditions
Acute respiratory failure
Oxygen therapy and mechanical ventilation

Key Diseases of the Digestive, Hepatobiliary, and Urinary Systems

Coding guidelines and key Coding Clinic references
Acute kidney injury/renal failure
Chronic kidney disease
Acute GI disorders
Chronic GI disorders
Liver disorders
Gallbladder disorders
Substance consumption

Neoplasms and Associated Diseases

Coding guidelines and key Coding Clinic references
TNM system

Day Four

Key Diseases Associated With the Circulatory System

Coding guidelines and key Coding Clinic references
Chest pain/angina/CAD
Heart failure
Acute myocardial infarction (AMI)

Key Diseases of the Nervous System and Mental Health

Coding guidelines and key Coding Clinic references
Traumatic brain injuries
Transient ischemic attack (TIA)/cerebrovascular accident (CVA)
– Hemorrhagic
– Ischemic
Altered mental status (AMS)
Seizures/epilepsy and convulsions

Key Endocrine, Nutritional, and Metabolic Diseases

Coding guidelines and key Coding Clinic references
Diabetes mellitus

Basic CDI Metrics and Professionalism

Basic CDI metrics
Minimizing vulnerabilities
Federal guidance and monitoring
Recovery Auditors (aka Recovery Audit Contractors or RACs)
Office of the Inspector General (OIG)
Professional ethics

*Agenda subject to change.

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