Online Training Course

Prod ID: 382
Bridging the Gap: Clinical Documentation & Coding

This class is designed to help coders work with providers to assess and gather the information needed in documentation to support appropriate code assignments. Class content is relevant for medical office professionals responsible for accurate medical coding and billing in an outpatient healthcare setting.




161 min



How do your skills measure up?

1. How effective are you at querying providers to extract complete and correct information from the documentation, i.e: "all of these words have to be in the documentation”?

2. Do you understand 7th character usage and difference between initial and subsequent?

3. Can you identify all the components necessary for the documentation to code to the highest degree of specificity?

4. Have you minimized the use of unspecified codes?

5. Do you know the dangers of missed revenue, denials, and audit risks with punitive consequences?

Coders are the caretakers of complete reimbursement in a value-based era. This class will help coders work with providers to assess and gather the information needed in documentation to support appropriate code assignments.

Class Highlights

  • Review of clinical documentation requirements for ICD-10-CM
  • Identify problems with clinical documentation
  • Provide strategies for maintaining effective communication and positive professional interaction between clinicians and coders
  • Focus on the documentation impact of patient quality care
  • Learn how quality reporting relates to clinical documentation
  • Establish guidelines for coding of medical records to their greatest level of specificity
  • Relay the value of ongoing performance measurement and support
  • Review common clinical documentation problems

Linda D'Spain


Linda is President of her medical practice management consulting firm, D'Spain Consulting. She travels the country conducting national seminars, workshops and webinars and consulting with physician practices, hospitals and medical societies on healthcare reimbursement, documentation guidelines, procedural and diagnostic coding, financial management, human resources, medical office management and compliance with fraud and abuse, OSHA, and HIPAA. She has also served as an Independent Review Organization (IRO) for the Office of the Inspector General and consulted for the Texas Medical and Dental Boards.

With more than 30 years of experience in medical practice management, Linda has managed cardiology, cardiothoracic, vascular surgery, physical therapy, orthopedics, pediatric orthopedics, gynecology and reproductive endocrinology and large multispecialty group practices. She maintained broad responsibilities in business and clinical operations, financial management, governance and organizational dynamics, human resource management, marketing, customer service, compliance, information system management, mergers and acquisitions and risk management.

Linda has attained all five PMI certifications. She also has a degree in Business Administration and is a Board Certified Medical Practice Executive through the American College of Medical Practice Executives, a member of the San Antonio Medical Group Managers Association (MGMA) and has served as an advisory board member with PMI.

This is an intermediate-level class. Content assumes knowledge of outpatient coding and reimbursement. Digital course materials included. Participants must have access to a current ICD-10-CM code set manual while taking this course.


Comments from past participants:

"This instructor did a great job at presenting the content and explained everything clearly."

"Very informational. I learned a lot!"

"Excellent program. This was a great training."

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