ADVANCE: Health Information Learning Resources Vol. 1, 2024

Health Information Management

Table of Contents

About the Book

Clinical Documentation Improve - ment: Principles and Practice clearly defines clinical documentation improvement (CDI), explains its im- portance, and presents an objective and uniform set of principles that can be applied reliably in any healthcare organization’s CDI program. Part I addresses the fundamentals of clinical documentation and provides guidance for making the decision to imple- ment a new program or improve the current one. Part II describes clinical documentation program implemen- tation—from staffing and training to ensuring program compliance. Finally, Part III recommends and explains a process for expanding and refining a clinical documentation program. ICD-10 will have an impact on the CDI process, highlighting specific coding scenarios functions are explained in detail • Includes a chapter on critical thinking for physicians, nurses, clinical documentation specialists, and coders Key Features • Explains how the transition to About the Author Pamela Carroll Hess , MA, RHIA, CCS, CDIP, CPC, is a health information management (HIM) professional with over 30 years of healthcare experience in revenue cycle operations, electronic health record (EHR) applications, healthcare informatics, data analytics, revenue integrity, HIM operations, compliance, quality control, clinical documentation programs, and provider education. Ms. Hess currently serves as vice president of strategy and operations with MedASTUTE Consulting, LLC, a consulting firm focused on leveraging analytics for performance improvement with healthcare providers and health plans. She has extensive experience as an HIM director in for-profit and nonprofit facilities.

Part I: Fundamentals of Clinical Documentation 1 Criteria for High-Quality Clinical Documentation 2 Types of Clinical Documentation 3 The Translation of Clinical Documentation in Coded Data 4 ICD-9-CM versus ICD‑10‑CM/PCS in Clinical Documentation Improvement 5 Assessing Clinical Documentation 6 Moving Forward with a CDI Program Part II: Implementing a Clinical Documentation Program 7 Staffing the Program 8 Physician Training 9 Training Nonphysician Clinicians and CDI Program Staff 10 Documentation Review and Physician Queries 11 Collecting, Analyzing, and Reporting on Program Data 12 Ensuring CDI Program Compliance Part III: Growing and Refining the Clinical Documentation Program 13 Continual CDI Program Renewal 14 CDI Best Practices: Operational and Financial 15 Synergies with the Electronic Health Record 16 Clinical Documentation Improvement Technology 17 Clinical Documentation Improvement: Multidisciplinary Team Approach 18 Growing the Clinical Documentation Improvement Program in All Patient- Care Areas 19 Critical Thinking Appendix A: Case Study: Using Data Analytics to Drive Physician Education Appendix B: Case Study: A Final Note for CDI Success Appendix C: Case Study: Sioux Valley Hospital USD Medical Center Appendix D: Case Study: St. Vincent Catholic Medical Center Appendix E: Case Study: University of Michigan Health System Online Resources Appendix F: FY 2015 Table 6I MCC List Appendix G: FY 2015 Table 6J CC List Appendix H: FY 2015 MS-DRG Table Appendix I: Query Examples Appendix J: Group Activities Appendix K: Example Physician Education PowerPoint Presentation Index

Outpatient clinical documentation improvement (CDI) is a vital step in the evolution of a comprehensive, overarching CDI program. Clinical Documentation Improvement for Outpatient Care: Design and Implementation is an all-inclusive guide to establishing and enhancing CDI programs for the outpatient and professional fee setting. It explains how to ensure sustainability and is a one-stop shop for information about regulatory changes that affect the healthcare industry.

Part I: Fundamentals of Outpatient Clinical Documentation 1 The Case for High-Quality Outpatient Clinical Documentation 2 Sources and Types of Outpatient Clinical Documentation 3 The Translation of Clinical Documentation into Coded Data 4 Regulation of Outpatient Healthcare and Compliant CDI Practice 5 Outpatient CDI Assessment 6 Analyzing Clinical Documentation Data 7 Assessing Outpatient CDI Program Technology Options Part II: Implementing an Outpatient Clinical Documentation Improvement Program 8 Moving Forward with a CDI Program 9 Creating Interdisciplinary CDI Leadership Teams in the Outpatient Healthcare Setting 10 Project Management Using a CDI Workplan 11 Program Staffing Options 12 Training the Outpatient Clinical Documentation Specialist 13 Provider and Clinical Staff CDI Education in the Outpatient Setting 14 Educational Programs for Outpatient Coders 15 Physician Queries In the Outpatient Setting 16 Expanding the Outpatient CDI Program Glossary Index

Key Features

• Can be used for standalone course work or as part of a class related to healthcare reimbursement • Content doubles as a professional toolkit and strategy guide for • Detailed case examples demon- strate real-world applications of essential outpatient CDI concepts • Includes an online workbook for students and professionals developing a best-in-class outpatient CDI program About the Author Pamela Carroll Hess , MA, RHIA, CCS, CDIP, CPC, is a health information management (HIM) professional with over 30 years of healthcare experience in revenue cycle operations, electronic health record applications, healthcare informatics, data analytics, revenue integrity, HIM operations, compliance, quality control, clinical documentation programs, and provider education. Ms. Hess currently serves as vice president of strategy and operations with MedASTUTE Consulting, LLC, a consulting firm focused on leveraging analytics for performance improvement with healthcare providers and health plans. She has extensive experience as an HIM director in for-profit and nonprofit facilities.

Clinical Documentation Improvement : Principles and Practice Pamela Carroll Hess , MA, RHIA, CCS, CDIP, CPC

Clinical Documentation Improvement for Outpatient Care : Design and Implementation Pamela Carroll Hess , MA, RHIA, CCS, CDIP, CPC

Product#: AB121717

EBOOK ONLY 392 pages Premier Member: $71.95 Member: $74.95 List: $89.95

ISBN: 978-1-58426-584-9 Softcover 416 pages Premier Member: $68.95 Member: $71.95 List: $89.95

Instructor Resources include the following: • Test bank • Presentation slides The test bank is also available in Respondus.

ebook Available e-ISBN: 978-1-58426-665-5

Instructor Resources include the following: • Instructor manual • Test bank • Answer key • Sample syllabi • Presentation slides The test bank is also available in Respondus.

ORDER my.ahima.org/store SAMPLE ahima.org/reviewcopy

AHIMA I ADVANCE