WGU C807 TASK 1 ESSENTIAL SKILLS FOR HEALTHCARE CODERS
& CDI SPECIALISTS |LATEST UPDATE WITH COMPLETE
SOLUTIONS
Task 1: Coding Management
C807: Healthcare Compliance
Denah Shirey
, Inpatient and Outpatient Coders
Inpatient and outpatient coders have several responsibilities within the HIM department. Coders
carefully review qualifying documentation within the health record to accurately assign diagnosis and
procedure codes for patient encounters. To accurately assign codes, coders must know and understand
the ICD-10-CM Official Coding Guidelines. Inpatient coders will also need to be familiar with ICD-10-PCS
coding guidelines to code procedures. Outpatient coders also need to know the CPT and HCPCS coding
guidelines to code their procedures and ancillary services. Coders also need to have basic anatomy,
physiology, pharmacology, and pathophysiology knowledge. Inpatient coders will use documents that
include the history and physical exam, progress notes, consultations, operative notes, and discharge
summaries to assign codes for all relevant diagnoses and procedures for the entire length of stay for the
inpatient encounter. Outpatient coders review the provider’s note from the specific encounter to assign
diagnosis codes and any procedure codes necessary to reflect the encounter. They may also be
responsible to code evaluation and management codes to reflect the amount of time and resources the
provider spent on the patient.
CDI Program
The clinical documentation improvement (CDI) program is becoming an important program at
many healthcare organizations. A CDI specialist reviews the health record documentation and ensures
that every diagnosis documented is supported clinically and that every condition being treated,
monitored, or evaluated is properly documented. This process generally includes querying providers to
clarify their documentation. Each CDI program is different, but they could also review encounters to
clarify conflicting documentation or documentation that is just generally unclear in the record. CDI
specialists often review cases concurrently, meaning while the patient is still in the hospital. The goal of
this concurrent review is to decrease the amount of time between the patient’s discharge and the billing
& CDI SPECIALISTS |LATEST UPDATE WITH COMPLETE
SOLUTIONS
Task 1: Coding Management
C807: Healthcare Compliance
Denah Shirey
, Inpatient and Outpatient Coders
Inpatient and outpatient coders have several responsibilities within the HIM department. Coders
carefully review qualifying documentation within the health record to accurately assign diagnosis and
procedure codes for patient encounters. To accurately assign codes, coders must know and understand
the ICD-10-CM Official Coding Guidelines. Inpatient coders will also need to be familiar with ICD-10-PCS
coding guidelines to code procedures. Outpatient coders also need to know the CPT and HCPCS coding
guidelines to code their procedures and ancillary services. Coders also need to have basic anatomy,
physiology, pharmacology, and pathophysiology knowledge. Inpatient coders will use documents that
include the history and physical exam, progress notes, consultations, operative notes, and discharge
summaries to assign codes for all relevant diagnoses and procedures for the entire length of stay for the
inpatient encounter. Outpatient coders review the provider’s note from the specific encounter to assign
diagnosis codes and any procedure codes necessary to reflect the encounter. They may also be
responsible to code evaluation and management codes to reflect the amount of time and resources the
provider spent on the patient.
CDI Program
The clinical documentation improvement (CDI) program is becoming an important program at
many healthcare organizations. A CDI specialist reviews the health record documentation and ensures
that every diagnosis documented is supported clinically and that every condition being treated,
monitored, or evaluated is properly documented. This process generally includes querying providers to
clarify their documentation. Each CDI program is different, but they could also review encounters to
clarify conflicting documentation or documentation that is just generally unclear in the record. CDI
specialists often review cases concurrently, meaning while the patient is still in the hospital. The goal of
this concurrent review is to decrease the amount of time between the patient’s discharge and the billing
