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- CCDS® Certified Clinical Documentation Specialist
Curriculum
- 10 Sections
- 32 Lessons
- 40 Hours
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- INTRODUCTION TO CLINICAL DOCUMENTATION INTEGRITY (CDI)3
- 1.1Overview of CDI: Understanding the role and significance of clinical documentation in healthcare.
- 1.2History and Evolution: Tracing the development of CDI practices and their impact on patient care and hospital operations.
- 1.3Current Trends and Future Directions: Exploring the latest advancements and emerging trends in CDI.
- HEALTHCARE AND CODING REGULATIONS4
- 2.1Inpatient Prospective Payment System (IPPS): Detailed exploration of IPPS, its impact on clinical documentation, and associated CMS regulations.
- 2.2Medical Coding Guidelines: In-depth understanding of ICD-10, CPT, and HCPCS codes; aligning documentation with coding requirements.
- 2.3Private Payer Regulations: Examining the regulations set forth by private insurers and their implications for CDI.
- 2.4Compliance and Ethical Standards: Ensuring adherence to ethical guidelines and legal requirements in clinical documentation.
- ANATOMY, PHYSIOLOGY, PHARMACOLOGY, AND PATHOPHYSIOLOGY3
- 3.1Anatomy and Physiology: Comprehensive review of human body systems and their relevance to accurate clinical documentation.
- 3.2Pharmacology: Understanding drug classifications, mechanisms of action, and their documentation in medical records.
- 3.3Pathophysiology: Identifying and documenting the underlying mechanisms of diseases and conditions.
- MEDICAL RECORD REVIEW AND ANALYSIS3
- 4.1Medical Record Components: Understanding the structure and key elements of medical records.
- 4.2Document Interpretation: Techniques for analyzing and interpreting complex medical records for accuracy and completeness.
- 4.3Identifying Documentation Gaps: Methods for detecting inconsistencies or missing information in clinical records.
- COMMUNICATION AND PHYSICIAN QUERY TECHNIQUES3
- 5.1Effective Communication Strategies: Developing communication skills to collaborate with healthcare providers effectively.
- 5.2Query Formulation: Crafting compliant and clear physician queries to clarify or improve documentation.
- 5.3Physician Engagement: Techniques for fostering positive relationships with physicians to enhance documentation quality.
- CMS QUALITY PROGRAMS AND REPORTABLE DIAGNOSES3
- 6.1CMS Quality Programs: Overview of CMS quality initiatives and their implications for clinical documentation.
- 6.2Reportable Diagnoses: Understanding which diagnoses impact quality metrics and require precise documentation.
- 6.3Performance Metrics: How CDI influences hospital quality scores, reimbursement, and patient outcomes.
- DATA MINING AND REPORTING FUNCTIONS3
- 7.1Data Collection Techniques: Strategies for gathering and analyzing data from clinical documentation.
- 7.2Benchmarking CDI Performance: Tools and methods for measuring and improving CDI program effectiveness.
- 7.3Reporting Tools: Utilizing software and tools for generating CDI reports to inform decision-making.
- CDI PROGRAM MANAGEMENT AND LEADERSHIP3
- 8.1Building and Managing a CDI Team: Roles, responsibilities, and best practices for leading a successful CDI team.
- 8.2Strategic Planning for CDI: Setting goals, developing policies, and aligning CDI initiatives with organizational objectives.
- 8.3Continuous Improvement: Techniques for ongoing assessment and enhancement of CDI processes.
- CASE STUDIES AND PRACTICAL APPLICATIONS3
- 9.1Real-World Scenarios: Analyzing and learning from real case studies to apply CDI principles in practice.
- 9.2Practical Exercises: Hands-on exercises to develop proficiency in medical record review, physician querying, and data analysis.
- 9.3Problem-Solving in CDI: Approaching complex CDI challenges and finding solutions through collaborative strategies.
- EXAM PREPARATION4
- 10.1Exam Overview: Understanding the structure and content of the CCDS® exam.
- 10.2Review Sessions: Focused review on key areas such as regulations, anatomy, and physician query techniques.
- 10.3Mock Exams: Practice tests to assess readiness and identify areas for further study.
- 10.4Study Resources: Guidance on utilizing available resources, including the CCDS® Exam Prep Guide and Boot Camps.