Take your clinical documentation integrity (CDI) department completely online and mobile. A query should not be suggestive of new information in a leading way, but rather should present facts available in the medical record that need clarification. Maximum advanced level continuing education contact hours available are 0. First, do your research about the profession and try to determine if youd actually like to step into this line of work. CBT 103 highlights essential components of effective feedback and discusses strategies to deliver feedback effectively. Describe the importance of interprofessional collaboration in healthcare settings. Specifically, participants learn about MS-DRG methodology, including how MS-DRGs are assigned and how documentation affects code assignment and sequencing. Analyze why your facility/practice needs a CDI program. By running reports of ICD-10-CM codes submitted on claims, reviewing the medical documentation, educating the provider on certain measures that have not been met, and educating the coding team to report these measures, the CDI specialist bridges the gap between clinical documentation and medical coding. implementing hand hygiene with soap and water as the preferred method at room exit with enhanced staff training and monitoring. Another fundamental purpose for codes is appropriate billing. RN/LPN. Improper claim submissions resulting from poor documentation can result in unfavorable audits, which could require facilities to pay a fine, return money erroneously collected from payers, or both. All rights reserved, September/October 2018 edition of the CDI Journal, Chapter Advisory Committee: Summer 2023 panel discussion for local leaders. See the American Hospital Associations HRET STRIVE page Getting Hospitals to Zeroexternal icon. Two rates are reported. CDI Boot CampOnline: How does it work? Regardless of location or size of the CDI team, clarification of clinical documentation in a medical chart is what drives a successful CDI program. Whether in an inpatient or outpatient setting, the success of a CDI program lies with the specialist. It provides strategies to engage senior leaders and physicians in quality improvement initiatives and highlights approaches for overcoming common barriers that arise during new initiatives and quality improvement work. The online portal for your class sessions and materials is accessible for 60 days from your purchase date. The Centers for Disease Control and Prevention is accredited as a provider of Continuing Nursing Education by the American Nurses . Sometimes retrospective CDI reviews can be weeks or even months after the date of service depending on the workflow of the CDI team. Developed by national infection prevention experts, the curriculum focuses on foundational and HAI-specific prevention practices. CEU: The Centers for Disease Control and Prevention is authorized by IACET to offer 0.1 CEUs for this program. This practice resulted in more accurate billing for the facility, and the CDI trend took hold. Provider offices rely on a healthy revenue cycle to ensure expenses and salaries are paid, but claim denials or amendments because of improper code submission can be disruptive to the timely receipt of payment for services rendered. For Certified Public Health Professionals (CPH). Copyright 2023 HCPro, a Simplify Compliance brand. MRSA 202: Outlines Tier 2 enhanced MRSA prevention strategies and how to implement them. Some community colleges offer one-year certificate programs on healthcare coding, so that part of the CDI role can be obtained through formal schooling.. CDC did not accept commercial support for this continuing education activity. CME: The Centers for Disease Control and Prevention designates this enduring activity for a maximum of 2.5 AMA PRA Category 1 Credits. This module also reviews the advantages of horizontal infection prevention strategies and the importance of following recommendations and best practices. Local chapter update: Have you signed up yet to attend the live panel discussion for chapter leaders? CECH: Sponsored by the Centers for Disease Control and Prevention, a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. implementing environmental cleaning process tools and using an EPA registered sporicidal agent, and. What are the top reasons for denials? For instance, the Hospital Readmissions Reduction Program (HRRP) is a value-based purchasing program that reduces payment to hospitals with excess readmissions. Discuss effective strategies used to engage clinicians and leaders in infection prevention efforts. ACDIS has a number of tips and resources to help you get up and running, though. https://acdis.org/sites/acdis/files/ACDIS_CCDS_CandidateHandbook_March2022.pdf, Coding and reporting requirements related to COVID-19 and its manifestations, The ICD-10-CM Official Guidelines for Coding and Reporting, as seen from a CDI perspective, Diagnoses frequently in need of additional documentation to support accurate code assignment across all major body systems, The value of compliant provider query practice and best practices associated with the query process, Core provider education concepts such as IPPS reimbursement, documentation integrity, and quality metrics, IPPS methodology based on MS-DRG assignment and the impact of diagnosis assignment and sequencing on hospital reimbursement, CDI benchmarking basics, compliance risks, and professional ethics, Implement a step-by-step process for thorough medical record review based on industry guidelines, Develop compliant verbal and written physician queries and understand how to effectively query providers, Recognize significant clinical indicators supporting problematic diagnoses such as heart failure, sepsis, acute renal failure, and encephalopathy, Understand the impact of compliance initiatives on CDI, including the Recovery Auditor program and the Office of Inspector General Work Plan, Principal diagnosis guidelines in ICD-10-CM, Impact of complications/comorbidities (CCs) and major CCs (MCCs), Poisoning, adverse effects, and underdosing, Oxygen therapy and mechanical ventilation, Transient ischemic attack (TIA)/cerebrovascular accident (CVA), Recovery Auditors (aka Recovery Audit Contractors or RACs), CDI specialists, CDI supervisors, CDI managers/directors, Inpatient coders, coding supervisors, coding managers/directors, Coding compliance specialists, coding compliance supervisors/managers/directors, Quality integrity professionals, quality department managers/directors, Utilization review/case management managers/directors, A current DRG Expert / DRG Expert is published by Optum Coding. Describe my role, responsibilities, and scope of practice as a team member. Look for both the good and the bad practices when implementing a CDI program; meaningful outcomes should be the driving force of sustainability and growth. Describe the components of the CDI Guide to Patient Safety (GPS) tool. CEU: The Centers for Disease Control and Prevention is authorized by IACET to offer 0.2 CEUs for this program. Asking these questions is a great start: What is the claim denial rate? Physicians should claim only the credit commensurate with the extent of their participation in the activity. Describe how C. difficile infection transmission occurs in health care settings. workplace with toolkits covering topics such as disaster planning, breach management, and, Certified Documentation Integrity Practitioner (CDIP, Clinical Data for CDI: Artificial Intelligence (AI), Clinical Documentation Improvement: Principles and Practice, Certified Documentation Improvement Practitioner (CDIP) Exam Preparation, Clinical Documentation Improvement for Outpatient Care, Care Beyond the Specialist Clinic: A collaboration to Bring Heart Failure patients the Best Care Using Technology, Clinical Documentation Integrity Insight Courses, Guidelines for Achieving a Compliant Query Practice, Clinical Documentation Integrity (CDI) Progression Ladder, The Importance of Implementing Clinically Intelligent Compliance Programs. The CDI Progression Ladder represents and supports all stages of a CDI professionals career, including the educational level of each product. CNE: The Centers for Disease Control and Prevention designates this activity for 2.1 nursing contact hours. . The ACDIS CDI Apprenticeship demonstrates that an individual has foundational CDI knowledge and has familiarity with the ACDIS Code of Ethics and other guiding principles for compliant query practice. Maximum advanced level continuing education contact hours available are 0. There are various organizations and programs that offer CDI training for RNs and other professionals seeking development. a. For more detailed information about HCPro's Boot Camps, contact us at 615-724-7200 or emailPD-IS@SimplifyCompliance.com. Consequently, depending on your background and experience, additional independent study and/or training may be required to pass the CCDS examination. All courses offer free continuing education on TCEO. If there is nonspecific terminology, uncertain diagnoses, diagnostic test results not addressed, or diagnoses in a consult report not reiterated by the attending physician, the CDI specialist can immediately query the provider. For Certified Public Health Professionals (CPH) Get CE for Personal Protective Equipment Course WB4225. In compliance with continuing education requirements, all presenters must disclose any financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. Check out all the benefits of this HCPro Boot Camp: Our boot camps are a comprehensive and effective way to strengthen your understanding of CDI. As a result, CDI programs were organized so that a team of nurses could concurrently review the inpatient medical record documentation and query a provider concerning anything ambiguous or not complete prior to claim submission. Communicating the findings of these retrospective reviews needs careful wording just as a query in a concurrent review does. HH 101 reviews the critical role of hand hygiene as a foundation for preventing HAIs and reviews proper hand hygiene technique as well as the key moments to perform hand hygiene. Click on the Register button. However, the course may not cover all the content areas tested on the exam. EC 102: Provides an overview of strategies to consider when training staff about cleaning and disinfection policies and procedures, and identifies tools to assist with monitoring and auditing these practices. The CDI nurse did not suggest the diagnosis of acute respiratory failure with hypoxia and hypercapnia, but, with the clinical facts, the query did prompt the provider to clarify a more specific diagnosis regarding the data available and treatment required. MDRO & CDI Training | PSC | NHSN | CDC A CDI program in the outpatient setting can have just as much financial impact as in the inpatient setting. The following other materials are optional, but may be helpful (note: These are NOT required): At the conclusion of the course, participants will be able to: In order to receive CE credits participants must complete the quiz that will be provided in the survey evaluation following the conclusion of this online boot camp. Multiple choice queries should include the options of clinically undetermined or not clinically significant. In Scenario 1 of this article, a query to the provider was mentioned that resulted in clarification that the patient had acute respiratory failure with hypoxia and hypercapnia in addition to a COPD exacerbation. To help providers succeed in this task, a CDI specialist is responsible for reviewing a patients medical record to ensure documentation reflects the specificity of current conditions to allow for accurate coding of the patients health status. Explain how the GPS assessment can be used to identify barriers to CLABSI prevention. The Centers for Disease Control and Prevention is a pre-approved provider of Certified in Public Health (CPH) recertification credits and is authorized to offer 3 CPH recertification credits for this program. CDI can be challenging if all parties involved in implementing a CDI program (physicians, administrators, CDI specialists, and coding and billing staff) do not understand the purpose and process of CDI and how each role is vital. There are 7 training modules that cover CAUTI. CAUTI201: Reviews using the CAUTI GPS and the TAP to establish focused goals and evaluate possible barriers to implementation of CAUTI prevention strategies. Please use another browser for shopping/ordering or contact customer service if you have trouble. Table 2 summarizes typical aspects of inpatient and outpatient CDI, but variations from these general statements is certainly possible. Define competency-based training at the completion of the module set. Understanding the DRG and IPPS Systems: Describes how to assign MS- and APR-DRGs, how hospitals are paid under the IPPS, and the nuances of the Medicare reimbursement system. Designation as an ACDIS CDI Apprentice demonstrates to potential employers that an individual has foundational knowledge of CDI. About CDI.edu: Accredited Los Angeles Nursing School. AMN Healthcare Revenue Cycle Solutions also has a CDI Academy that includes lessons for aspiring CDI professionals. We spoke with Karen Newhouser, of AMN Healthcare Revenue Cycle Solutions, to outline the CDI profession and how an RN can successfully transition to a CDI career. Physicians should claim only the credit commensurate with the extent of their participation in the activity. CAUTI202: Outlines Tier 2 CAUTI prevention strategies and how to implement complex interventions such as conducting catheter rounds with targeted education, providing infection and catheter utilization metrics to frontline staff, observing and documenting competencies, and performing a full root cause analysis of every CAUTI. Becoming an AHIMA-Approved Clinical Documentation Integrity (CDI) Trainer can help you take your CDI career to the next level. Register and Attend an Upcoming Training. Describe a tiered approach to methicillin-resistant. Many non-Medicare payers use an adaptation of this DRG payment system, as well. ACDIS tips: Getting started in CDI | ACDIS Maximum advanced level continuing education contact hours available are 0. EC 101: Describes the important role that the hospital environment can play in pathogen transmission and shares useful concepts to improve a hospital cleaning and disinfection program. The ACDIS CDI Apprenticeship can be used as a pathway for progression toward the goal of CCDS certification and those who participate in the ACDIS CDI Apprenticeship will receive regular networking opportunities, special offers on further education, and support to continue on the journey. In addition to our online and open registration courses, we also offer the CDI Boot Camp as an on-site course (with a substantial discount) for organizations that have a number of employees who need training. Learn the fundamentals of clinical documentation, how to implement a CDI program, and how to grow and refine an existing program. For more information about the CDI Apprenticeship program, click here. Next, once you know youd like to step into the CDI world, connect with some CDI professionals in your geographic area and ask if you can shadow them or just pick their brains. CAUTI104: Reviews Tier 1 interventions such as including indwelling urinary catheter insertion and maintenance bundles and highlights the importance of proper catheter insertion and care as a means to prevent CAUTI. The primary focus of a CDI program for physicians in an office or outpatient environment is to help prevent these denials and amendments while also ensuring documentation is complete for clinical purposes. Are we providing quality patient care to meet payer contract requirements? Since most hospitals have CDI professionals on staff, this is an efficient avenue to hear their perspective on the role. Accurate claim submission, favorable audit results, a healthy revenue cycle, and better health outcomes for the patient are all reasons to implement a CDI program. For example, just because the provider did not state a patients diabetes mellitus was controlled based on expected lab values does not mean the CDI specialist would query the provider. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Candidates who pass the final exam receive a certificate of CDI foundational training and are allowed to designate themselves as an ACDIS-Approved CDI Apprentice. This module also introduces tools and Tier 1 strategies to avoid unnecessary catheter use and improve clinical decision-making. Maximum advanced level continuing education contact hours available are 0. AHIMA is committed to advancing clinical documentation improvement (CDI) by providing education and training, certification . There is one training module that covers Patient and Family Engagement. I would seek out CDI professionals within their place of employment, Newhouser says. Medicare Severity Diagnosis Related Groups (MS-DRGs). The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. This course is composed of three modules, each focuses on a specific healthcare setting. CECH: Sponsored by the Centers for Disease Control and Prevention, a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. ourse series includes 21 webinars that provides a comprehensive educational approach to CDI based on body systems and diagnostic categories. In a providers office, the CDI specialist will review the medical record and identify issues like these: Medication is prescribed but the condition for which it is prescribed is not listed. After updates, the CDI specialist can continue to assist by reviewing documentation and claims to validate the diagnosis codes accurately reflect what the provider recorded and support medical necessity for the level of E/M code reported on the claim. Identify how audit and feedback can be used to drive CDI prevention activities. But ensuring all conditions that are clinically supported get reported is equally important because of how inpatient facility reimbursement works. AHIMA is committed to advancing CDI by providing education and training, certification (CDIP credential), and other valuable resources to CDI professionals. Upon passing the final exam, youll be allowed to use the designation of ACDIS-Approved CDI Apprentice on your resume, in your biographical information, or in your email signature to set you apart from other potential applicants. Improve your CDI know-how with ACDIS-endorsed best practices for medical record review and compliant physician querying. Describe a tiered approach to Clostridium difficile infection (CDI) prevention. Describes the overarching socio-adaptive issues to consider when implementing quality improvement work. The Association of Clinical Documentation Integrity Specialists (ACDIS) is proud to launch a new certificate program for those seeking to enter the clinical documentation profession. Whether you are new to CDI, transitioning from a coding or clinical background, or an experienced CDI professional, AHIMA provides education and resources to support your lifelong learning and continued advancement. Developed by national infection prevention experts, the curriculum focuses on foundational and targeted infection prevention practices. The clinical courses in the review the pathophysiology, critical coding guidelines, and documentation requirements for these conditions, as well as providing sample queries. Each course has 1 or more modules. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Both of these backgrounds provide a good foundation to become a CDI professional. Become a Nurse Assistant | Red Cross BUY COURSE Prepare for the Certified Clinical Documentation Specialist (CCDS) exam with Nurse.com's CCDS certification test prep course. HH 102 illustrates different methods to use to monitor hand hygiene adherenec and components to include on monitoring tools and feedback reports about hand hygiene adherence. CEU: The Centers for Disease Control and Prevention is authorized by IACET to offer 0.2 CEUs for this program. Clinical Documentation Integrity Education & Training | AHIMA CME: The Centers for Disease Control and Prevention designates this enduring activity for a maximum of 1.25 AMA PRA Category 1 Credits. Hospital infection control training on a variety of infection prevention topics including Tier 1 and Tier 2 interventions. Trusted by hundreds of CDI specialists as the go-to source for CDI education, this course defines the role of CDI specialists and provides comprehensive training on their responsibilities. Hospitals are familiar with and subject to various types of audits. CDI Boot Camp Onlinesee the difference for yourself! Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis. As an example, theCPT2021 evaluation and management (E/M)guidelines for office and other outpatient visits changed from typically requiring key elements such as history, exam, and medical decision making (MDM) to basing the level of the visit on MDM or time.