Clinical Documentation Improvement Assignment

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Health Medical

Description

Clinical Documentation Improvement (CDI) Specialists play a critical role in helping physicians and healthcare organizations decrease denied claims by improving the quality of documentation in the patient record. Not only does this improved document support ICD coding but also is used to ensure patient safety and quality indicators, which will impact third party value-based purchasing initiatives.

Since healthcare has transitioned from ICD-9-CM to ICD-10-CM/PCS, CDI Specialists will be working even more closely with physicians and coders to increase their understanding of how ICD-10-CM/PCS changes the depth of documentation needed.

Learning about CDI (Clinical Documentation Improvement) is a critical function in healthcare. Accurate and effective coding is a critical component of any successful CDI Program. It is important as a coder to fully understand how coding and CDI work together to improve the quality of documentation.

Please finish the worksheet attached below.

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Complete the parts for this worksheet below. If you’re unsure of any terms used be sure to research the terms and increase your knowledge. Example: Job Site URL Location: Job Duties Collaborates with HIM coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers Facilitate appropriate and timely clinical documentation to ensure that level of services and acuity are accurately reflected in the medical record. Does this job align with what you learned when you reviewed the AHIMA Career Map? Reflective Statement Page 1 of 2 https://www.healthcaresource.com Skill set and/or knowledge What HIM function is related • Good communication • Coding skills • Reimbursement • Coding skills • Case mix index review • Chart review skills • Data processing • Data presentation skills • DRG Assignment • SOI and ROM knowledge • POA • • • • Good verbal and written communication skills Be an educator Biomedical knowledge Knowledge of timely completion requirements and standards by external forces • Knowledge of SOI and ROM criteria Explain your answer: • • Query process Coding • Completion chart review Quality management • Start by telling us if this is a job you would want, why or why not? Part 1: AHIMA Career Map Questions What is the Promotional Pathway What is the Transitional Pathway What skills are required List Job Responsibilities Your findings Part 2: CDI Job Responsibility and Skill Sets Job Site URL (Verifiable) Job Duties Does this job align with what you learned when you reviewed the AHIMA Career Map? Reflective Statement Page 2 of 2 Skill set and/or knowledge What HIM function is related Explain your answer: Start by stating if this is a job you would want, why or why not?
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Explanation & Answer

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Running head: CLINICAL DOCUMENTATION IMPROVEMENT

Clinical Documentation Improvement
Name
Tutor
Institution
Course
Date

1

CLINICAL DOCUMENTATION IMPROVEMENT
Job Site URL Location:
Job Duties
Collaborates with HIM coding
staff to ensure that appropriate
reimbursement is received for
the level of services rendered to
patients and the clinical
information utilized in profiling
and reporting outcomes is
complete and accurate
Obtain appropriate clinical
documentation through
extensive interaction with
physicians, nursing staff, other
patient care givers
Facilitate appropriate and
timely clinical documentation
to ensure that level of services
and acuity are accurately
reflected in the medical record.
Does this job align with what
you learn...

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