Bridging the Gap - Clinical Documentation and Coding
How do your skills
measure up?
- How effective are you at
querying providers to extract complete and correct information from the
documentation?
- Do you understand 7th
character usage and the difference between initial and subsequent?
- Can you identify all the components necessary in the documentation to code to the highest degree of specificity?
- Have you minimized the use of
unspecified codes?
- Are you aware of the risks and potential consequences with copy/paste and cloning records that result in improper reimbursement?
All healthcare providers must ensure that the claims submitted to Federal healthcare programs are true and accurate.
This class will help medical coders work with clinical providers to assess and gather the information needed in documentation to
support appropriate code assignments.
Learning objectives:
- Review clinical documentation requirements for ICD-10-CM and identify
problems with clinical documentation.
- Develop strategies for maintaining effective communication and positive
professional interactions between clinicians and coders.
- Understand the documentation impact of patient quality care and importance of establishing guidelines for documenting and coding to the greatest level of specificity.
- Review the scope and steps for an effective compliance plan and know what to do if you have information about fraud or abuse.
- Gain
confidence by engaging with documentation examples and practicing writing
different forms of physician queries.
Who Should Attend
Course content is relevant
for medical office professionals responsible for accurate medical coding and
billing in an outpatient healthcare setting. This program is designed for coders, auditors, providers, clinical, and practice staff involved in medical coding. Consultants, compliance officers, and office managers may also benefit.
Prerequisites
Content assumes basic level
knowledge of outpatient coding and reimbursement. Access to a current ICD-10-CM code set manual or resource
is required for full participation and completion of included clinical scenario
exercises.
Class Materials
Registartion includes companion instructional materials to serve as a resource beyond the classroom.
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Earn 3 PMI CEUs for attendance at this program. Practice Management Institute grants CEUs for its certified professionals based on total number of instructional hours (1 CEU per hour of classroom instruction). CEUs may be applied to annual recertification requirements, as directed in the certification renewal requirements for your credential(s).