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Home > Curriculum > Bridging the Gap between Clinical Documentation and Coding

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 in the documentation to code to the highest degree of specificity?

4. Have you minimized use of unspecified codes?

5. Are you aware that there can be serious consequences with copy/paste and cloning records resulting in improper reimbursement?

All health care providers have a duty to ensure that the claims submitted to Federal health care programs are true and accurate. 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, such as copy/paste/cloning
  • Provide strategies for maintaining effective communication and positive professional interaction between clinicians and coders
  • Focus on the documentation impact of patient quality care
  • Establish guidelines for documenting and coding of medical records to their greatest level of specificity
  • Review the scope and steps for an effective compliance plan
  • Learn what to do if you have information about fraud or abuse in your organization
  • Engage in hands-on practice with documentation examples and writing different forms of queries

Who Should Attend

Class 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

This is an intermediate-level class. Content assumes knowledge of outpatient coding and reimbursement.

Class Materials

A course manual will be provided. Participants must bring a current ICD-10-CM code set manual to class.


Clinical Documentation and Coding

Program Schedule

There are no live classes available at this time. See below for more options.

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  • Bring an Instructor onsite for group training. Contact info@pmiMD.com or call 800-259-5562, M-F, 8-5 Central
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  • Continuing Education Units (CEUs)

    PMI CEU APPROVED 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).

    If you are seeking CEU credits for other certifications or organizations, please contact your organization for pre-approval and credit guidelines. A certificate of attendance will be provided.

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