Description
The course will focus on the review of medical record cases and the discussion of opportunities for documentation improvement of diagnoses and procedures. This discussion focuses on the level of specificity, diagnoses present on admission and the develop of queries. Other topics discussed are the potential for fraud, possible compliance issues, conflicting diagnoses, abnormal findings, and post-discharge query opportunities. The administrative requirements for queries are also studied including the requirements for documentation of query response and tracking the queries. Students will develop policies for documentation of query responses in the record to establish official policy and procedures related to CDI query activities. Students will also study and develop policies regarding various stages of the query process and time frames to avoid compliance risk. Using coding software, assign and sequence diagnostic and procedural codes following all coding conventions and with considera