Clinical Documentation Improvement

Instructor: Dorothy Steed
Product ID: 703367
Training Level: Intermediate
  • Duration: 60 Min

recorded version

1x Person - Unlimited viewing for 6 Months
(For multiple locations contact Customer Care)
Recorded Link and Ref. material will be available in My CO Section
Last Recorded Date: Jun-2016

Training CD / USB Drive

One CD/USB is for usage in one location only.
(For multiple locations contact Customer Care)
CD/USB and Ref. material will be shipped within 15 business days

Customer Care

Fax: +1-650-362-2367


Read Frequently Asked Questions

Clinical documentation is the cornerstone for all patient medical records: the information ensures optimal patient outcomes and supports research, medical coding and other uses of the medical record. This training program will discuss clinical documentation improvement to ensure its purpose, i.e., to adequately relate the patient’s current and historical conditions and treatments with primary focus placed on situations that affect the current medical encounter. It also supports the provider’s defense should the case become a legal issue.

Why Should You Attend:

The upcoming ICD-10 code set will require explicit documentation of conditions and treatments in order to support the severity of patients under treatment as well as allow for the significant specificity required by this new code set. Ambiguous documentation and generic coding will no longer guarantee reimbursement, but will possibly generate a claims denial for lack of medical necessity.

This session will review the theory of high-quality clinical documentation which has the support of healthcare regulatory guidelines and peer-review research. Additional consideration involves medical outcomes that may result in legal actions. When clinical documentation is vague, missing key elements and conflicting statements, the provider may find that he/she is handicapped in supporting medical decisions and patient results, particularly when the result is a negative outcome for the patient.

In today’s healthcare environment, many patients have become educated consumers of medical services. They are more inclined to request their own medical record, carefully review explanation of benefits from payers, and request a review of any information they deem to be incomplete or questionable.

This webinar will review examples of documentation that does not meet the standard of high quality clinical documentation, including:

  • Review of 7 criteria that all entries in the medical record should include
  • Impact of documentation on coding and claims
  • Establishing a CDI team
  • CAMP methodology of documentation improvement

Areas Covered in the Webinar:

  • Significance of abnormal lab results. How to query provider.
  • Measurement of lesions, when taken and inclusion of margins. Why it matters and how reimbursement may be affected.
  • Start and stop times and methodology for infusions and discrepancies in billing. Complete reporting for administration and substance.
  • Diagnostic testing and medications should be supported in a diagnosis. Unsupported documentation may cost you money.
  • Depth of wounds and cause should be clear. Clarity needed for both depth and origin of wound.
  • Severity of illness. Hospitals and payers are increasingly scrutinizing patient severity. Lack of detail costs money.
  • Diagnosis present on admission? Certain conditions do not generate additional revenue if occurrence after admission.

Who Will Benefit:

  • Coding
  • Billing
  • Revenue Cycle
  • Physicians
  • Mid-Level Providers
  • Nurses
  • Claims Follow-Up
  • Managers

Instructor Profile:

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 39 years of experience in healthcare. Additionally, she is an instructor at a state technical college in Atlanta, provides auditing and training in both facility and physician services, and has been a speaker at several healthcare conferences.

Ms. Steed has written articles for several medical publishers and served as a contributing author for medical billing and coding training material. She writes online courses, and is an AHIMA certified ICD-10 trainer, both CM and PCS. Ms. Steed is credentialed in medical coding, clinical documentation improvement, medical billing, medical auditing, utilization management, healthcare management, healthcare compliance and patient accounts. She holds a Bachelor’s degree with a major in business and minors in both criminal justice and sociology.

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Refund Policy

Registrants may cancel up to two working days prior to the course start date and will receive a letter of credit to be used towards a future course up to one year from date of issuance. ComplianceOnline would process/provide refund if the Live Webinar has been cancelled. The attendee could choose between the recorded version of the webinar or refund for any cancelled webinar. Refunds will not be given to participants who do not show up for the webinar. On-Demand Recordings can be requested in exchange.

Webinar may be cancelled due to lack of enrolment or unavoidable factors. Registrants will be notified 24hours in advance if a cancellation occurs. Substitutions can happen any time.

If you have any concern about the content of the webinar and not satisfied please contact us at below email or by call mentioning your feedback for resolution of the matter.

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