Clinical Documentation Toolkit (completely solved)

What is CDI? correct answers Any manual or electronic notation made by a clinical care provider or their authorized "medical scribe." What is the purpose of CDI? correct answers The diagnosis and procedures documented in the record need to be clearly supported by clinical indicators so that the ICD-10-CM/PCS codes assigned are accurate and correctly assigned. Written Query correct answers The method of clarification used by CDI professionals. Verbal and electronic are also methods documented in the health record to make contact with the Physician. Benefits of CDI Program correct answers Accuracy and completeness in documentation, coding, reimbursement and severity of illness [SOI] and risk of mortality [ROM] classifications. How to begin a CDI Program correct answers A focused concurrent review of a specific payer type (such as Medicare) or payment type (such as DRG). Where are CDI Programs found? correct answers CDI programs are typically found in the acute inpatient setting, they also exist in other healthcare settings such a provider offices, ambulatory care, acute rehabilitation hospitals, amd skilled nursing facilities. Who are the CDI staff? correct answers HIM Coding Professionals, Nurses, Provider Liaisons or Provider Champions who conduct reviews and communicate with other providers on documentation issues. Knowledge, Skills, and Attributes of CDI Professionals correct answers Clinical Knowledge Payment Systems Methodologies ICD-10-CM/PCS Coding Concepts and guidelines, Regulatory Compliance, experience in Hospital acute care, and strong verbal and written communication skills. Terms for "CDI Professionals" correct answers CDIP: Clinical Documentation Improvement Practitioner CDIS: Clinical Documentation Improvement Specialist CDS: Clinical Documentation Specialist Who are Key CDI Stakeholders? correct answers CDI programs are seen as a bridge between a host of professionals HIM and Coding Departments Case Management and Utilization Review Medical Staff and Provider Leadership Executive Leadership