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CDI Academy: Foundational CDI education and clinical conditions every CDI specialist and Inpatient Coders need to know

YES HIM Consulting developed the CDI Academy with the objective of providing coding professionals or experienced inpatient coders, CDI professionals, those who are entering the CDI profession or related roles in the healthcare setting a comprehensive program of 5 modules with a practical approach covering foundational CDI education combined with clinical conditions that every CDI specialist must understand and master to ensure compliant practice. The experienced inpatient coder will also benefit from the detailed review of clinical criteria presented along with the review of AHIMA’s Guidelines for Achieving a Compliant Query Practice. Learners will study CDI best practices through real-life examples and assessment activities that draw from lesson-specific clinical and coding topics.

Completion of the Academy provides 8 pre-approved AAPC CEUs and can be used towards 8 AHIMA CEUs. Expected time to complete Academy: 10-14 hours.

CDI Academy Educators:

Amy Davis, RHIA, CDIP, Director, Coding and CDI for YES HIM Consulting, Inc.

Amy Davis has in depth knowledge of health information operations with an emphasis on coding and reimbursement and significant experience with implementation of quality improvement systems to comply with Joint Commission and regulatory agency standards. Amy has been a Manager of Coding and Operations in an acute care setting and has assisted with implementation and training on the Cerner Document Imaging System and managing the Recovery Audit process. She has taught coding and medical terminology classes and participated in the clinical documentation improvement process. Amy is an AHIMA-approved ICD-10-CM/PCS Trainer and a Clinical Documentation Improvement Practitioner.

Patricia J. Brown, MS, RHIA, Contract Senior Auditor for YES HIM Consulting, Inc.

Pat Brown has wide-ranging experience in the HIM field including Director of HIM operations for large (over 600 beds) acute care hospitals, Founder and Director of HIT Education Program and Vice President for a national HIM consulting services provider.  For the past 10 years, Pat has co-authored ICD-10-CM and ICD-10-PCS Inpatient Coding Education materials and performed ICD-10-CM and ICD-10-PCS concurrent and retrospective MSDRG and coding audits.

Required Book:  Essentials for Clinical Documentation Integrity 2019, MedLearn Publishing, A Division of MedLearn Media, Inc.

https://shop.medlearn.com/essentials_clinical_documentation_integrity_p/pcds.htm

CDI Academy Learning Objectives:

The CDI academy includes five courses that provide an overview of the fundamental tools needed to establish and maintain a successful CDI program.    

Week One Course

Week One Course defines the historical relationship between clinical documentation and medical coding, the development and evolution of the Inpatient Prospective Payment System (IPPS) and the basics of clinical documentation integrity. Other topics included in this course are: AHIMA Standard of Ethical Coding, Present on Admission indicators, Hospital Acquired Conditions, Severity of Illness and Risk of Mortality scores. 

The Learner will be able to:

  • Identify what is Clinical Documentation
  • Discuss Clinical Documentation and Medical Coding
  • Describe POA indicators, HACs, SOI/ROM scores
  • Review AHIMA Standard of Ethical Coding
  • Detail Clinical Documentation Integrity Basics

Week Two Course

Week Two Course introduces the clinical validation review process and clinical indicators. The course includes examples of ICD-10-CM Official Coding Guidelines and Coding Clinic reference articles that pertain to clinical criteria and indicators regarding respiratory, cardiovascular and sepsis code assignment.

The Learner will be able to:

  • Continue the identification of Clinical Validation
  • Identify the Clinical Validation review process
  • Review the ICD-10-CM Official Coding Guidelines along with AHA Coding Clinic article references
  • Examine Clinical Criteria and Code Assignment
  • Review and describe Clinical Indicators

Week Three Course

Week Three Course defines physician query basics (What/How/Who) utilizing the AHIMA Guidelines for Achieving a Compliant Query Practice to illustrate the compliant query process.

The Learner will be able to:

  • Define a Query
  • Analyze the Query Process
  • Review Compliant Query Practice 
  • Discuss when to Query

Week Four Course

Week 4 Course provides hands-on application of knowledge acquired from the previous weeks’ CDI Academy courses by using actual case studies to illustrate the clinical documentation review and query processes. The case studies include Respiratory Failure, Pneumonia, Acute Renal Failure, CHF, Malnutrition, Sepsis, and Encephalopathy. 

The Learner will be able to:

  • Obtain hands-on application experience reviewing actual case studies
  • Apply knowledge to perform clinical documentation reviews
  • Review Case Studies in various diagnoses including Respiratory Failure, Pneumonia, Acute Renal Failure, CHF, Malnutrition, Sepsis, and Encephalopathy
  • Identify query opportunities

Week Five Course

Week Five Course defines common types of CDI program metrics.  Examples are provided for data trend analysis that can be used to measure success and identify areas of improvement for CDI programs.

The Learner will be able to:

  • Discuss the importance of CDI Metrics
  • Describe the various types of CDI Metrics
  • Examine Query Review Metrics
  • Review risk areas from the Medicare PEPPER Report
  • Analyze Data Trends from example hospital reports
  • Evaluate an example financial impact report