Clinical Documentation Improvement

Clinical Documentation ImprovementBy: Quita Edwards, CPC, CPMA, CPC-I, COSC ii AAPC 1-800-626-CODE (2633) CPT copyright 2011 American medical Association. All rights This course was current at the time it was published. This course was prepared as a tool to assist the participant in educat-ing providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains commonly accepted aspects of selecting Evaluation and Management (E/M) codes, but it is not a legal document.

z The Electronic Medical Record z Mastering the Documentation Process z The Impact of ICD-10 on Clinical Documentation z Coding and Abstracting z Implementation of a CDI program z Hands-on Activities Chapter 1: The Role of the Clinical Documentation Specialist Many large practices or facilities will employ a CDS to

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  Medical, Clinical, Record, Improvement, Documentation, Medical records, Clinical documentation, Abstracting, Clinical documentation improvement

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