Clinical Documentation Improvement

Event Information
Product Format
Prerecorded Event
Presenter(s)
Dorothy D. Steed, CCS, CDIP, COC, CPCO, CPUM, CPUR, CPHM, CPMA, ACS-OP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS,
Length
60 Minutes
Product Description

Create a documentation improvement team with specific responsibilities.

When you improve your clinical documentation, your claims will move through the reimbursement process with ease and bolster your bottom line. Whether you need help or only need to review the fundamentals, check out these tried-and-true strategies.

Expert presenter Dorothy D. Steed will show you how to review six points of high quality evidence based clinical documentation and highlight seven criteria that all entries in a patient record should include. You’ll walk away understanding the impact of documentation on coding and claims.

Create an action-plan. Establish a clinical documentation improvement team to assess the common areas of weakness in your clinical documentation, what coding/billing aspects are not supported in the medical record, and the CAMP methodology of documentation improvement. Your team can then determine the documentation improvement responsibilities.

This session will help you:

  • Determine the significance of abnormal lab results.
  • Show you how your documentation must reflect the correct measurement of lesions, when taken and inclusion of margins.
  • Highlight start and stop times as well as the methodology for infusions. You’ll likely uncover discrepancies in billing.
  • Here’s how your diagnostic testing and medications should be supported.
  • Clarify the depth of wounds and cause.
  • Include the severity of illness.
  • Ask, was the diagnosis present on admission?
  • Understand the impact and importance of documentation on coding and claims
  • Establish a clinical documentation improvement team to assess the common areas of weakness in your clinical documentation
  • 7 criteria for quality clinical documentation
  • Objectives and goals of clinical documentation improvement
  • Identify the common problematic areas of clinical documentation
  • What is the CAMP method for training physicians in CDI
  • Understand the Evidence-based – Theory of high quality clinical documentation
  • Importance of monitoring the program

Who should attend? Coders, billers, revenue cycle, physicians, mid-level providers, nurses,  claims follow-up, managers

Order Below or Call 1-866-458-2965 Today

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Phone

1-866-458-2965

Fax

1-919-287-2643

About Our Speaker

Dorothy D. Steed - Medical Coding and Billing Expert

Dorothy D. Steed, CCS, CDIP, COC, CPCO, CPUM, CPUR, CPHM, CPMA, ACS-OP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, is an independent healthcare consultant and educator in Atlanta. She was a Medicare specialist for a large hospital system and a physician coding audit supervisor for another hospital system, with 40 years of experience in healthcare. Additionally, she is an instructor at a state technical college in...   More Info
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