Bridging the Gap - Clinical Documentation and Coding
How do your skills
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
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.
of clinical documentation requirements for ICD-10-CM
problems with clinical documentation, such as copy/paste/cloning
strategies for maintaining effective communication and positive
professional interaction between clinicians and coders
on the documentation impact of patient quality care
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.
This is an
intermediate-level class. Content assumes knowledge of outpatient coding and
A course manual will be
provided. Participants must bring a current ICD-10-CM code set manual to class.