Module 1: The purpose of Inpatient Clinical Documentation Improvement Programs
- Understand the importance of medical documentation
- Master the documentation process
- Implement a CDI program
Module 2: Documentation Requirements
- Understand the medical record
- Identify ownership and access to the medical record
- Summarize HIPAA
- Identify and summarize regulatory guidance for the medical record
- List the components of the medical record
Module 3: Provider communication and compliance
- Identify regulations such as the false claims Act, Exclusion statute,and monetary penalties law
- Describe the OIG identify publications of the OIG
- Summarize recovery Audit contracts (RACs)
- List of physicians queries
- Describe how to write compliant query
- Explain the mindset of a physician for effective communication
Module 4: Quality measures
- Demonstrate knowledge of the hospital value-based purchasing program
- Describe patient safety and quality indicators
- Explain the hospital readmission reduction program
- Explain Vizient
Module 5: CMS and Inpatient payment systems
- List common inpatient payment system reimbursement methodologies
- Define inpatients stays
- Explain the discharge status disposition
- Describe diagnostic related groups and how they affect reimbursement
- Define rules affecting inpatient admissions
- Identify hospital acquired conditions
- Explain the hospital Inpatient Quality Reporting Program
- Define major diagnostic categories, Medicare Severity- Diagnostic Related Groups and All Patient Refined - Diagnosis Related Group
- List the steps to determine the Ms- DRGS
Module 6: Introduction to ICD-10-CM
- Describe how to look up an ICD-10-CM code
- Apply ICD-10-CM coding guidelines
Module 7: Clinical conditions & Diagnosis Coding Part 1
Define the condition, signs and symptoms, testing, treatments, coding concepts,guidelines for the following condition
- Congenital versus acquired conditions (general)
- HIV/AIDS
- Sepsis
- Neoplasms
- Adjuvant therapy
- Active versus history of neoplasms
- Metastatic
- Anemia and polycythemia
- Diabetes
- Malnutrition
- Drug dependence
- Major depression
- Common conditions of ear
- CAD
- Neuropathy
- Aortic aneurysm
- Aortic stenosis
- Cardiac conduction condition
- CVA vs TIA
- Heart failure
- Hypertension
- Hypoxia
- Myocardial infarction
- Peripheral vascular disease
- Pneumonia
- Cirrhosis
- Chronic obstructive pulmonary disease
- Crohn’s disease
- Hemiplegia
- Deep vein thrombosis
Module 8: Clinical conditions & Diagnosis Coding Part 2
Define the conditions , sign and symptoms, testing, treatments, coding concepts, guidelines for the following guidance:
- Pressure ulcers
- Rheumatoid arthritis
- Pathological osteoporosis fractures
- Chronic kidney disease
- Common conditions in pregnancy
- Burns
- Fractures
- Head injury
- Artificial openings
- COVID-19
- Transplant status
- Amputation
Module 9: ICD -10 PCS coding and guidelines
- Identify the structure of ICD-10-PCS code book
- Determine how to use ICD-10-PCS code book to determine code selection based on documentation
- Describe official guidelines for ICD-10 PCS
Module 10: Inpatient coding and documentation review
- Determine the principal diagnosis,admitting diagnosis,and additional diagnosis code sequencing
- Define and apply present on admission (PAO) indicators
- Review documentation dissection and query writing example
Complementary Module 1: Soft Skills Development
- Business Communication
- Preparation for the Interview
- Presentation Skills
Complimentary Module 2: Resume Writing

Resume Building Techniques

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