2022 CDI Basics of Provider Documentation [IEM]

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Overview: Basics of Provider Documentation

CDI and Quality depts. routinely track coding results that affect their business lines.  This data has indicated a need for understanding the implications of coding on many metrics that both hospitals and clinics follow to include, but not limited to: accuracy of primary dxs, LOS, DRGs, Readmission, Mortality, PSIs, HACs, and POA indicators.  The need for continued conversations regarding these various metrics, indicates the need for more formalized resources available to educate providers.

Target Audience

Physicians and Advanced Practice Providers and Residents of the Baylor Scott & White Health System

Learning Objectives

After participating in this activity, the learner should be able to:

1.Identify how provider documentation impacts hospital coding.
2.Review how DRG is determined based on documentation.
3.Review risk adjustment and how to capture risk adjusting conditions.
 
 

For further study:

•Optum 360 2018 DRG Expert. A comprehensive guidebook to the DRG classification system using the ICD-10-CM and _PCS code sets
Course summary
Available credit: 
  • 0.25 American Board of Internal Medicine (ABIM) MOC Part 2
    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
  • 0.25 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 0.25 Attendance
Course opens: 
12/01/2022
Course expires: 
12/30/2022
Learn Platform
Temple, TX 76504
United States

Planners/Authors: 

  • Sunita Varghees, MD, PhD, CHCQM, VP System Clinical Documentation Improvement
  • Elizabeth Aguirre, MD, Clinical Documentation Improvement Program; Inpatient Clinical Documentation Physician Lead

Content/Time Reviewers:

  • Yoon Sin Kim, MD

Disclosure of Relevant Financial Relationships:

  • This content is not related to products or business lines of an ACCME-defined ineligible company.
  • There are no relevant financial relationships with ACCME-defined ineligible company for anyone who was in control of the content of this activity.

Commercial Support:

No commercial support was received for this activity.

Accreditation: The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Designation: The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health, designates this enduring material activity for a maximum of 0.25 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Maintenance of Certification:
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 Medical Knowledge MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit

This CME activity type is an enduring material.  Physicians who complete the enduring material may claim the full amount of credit designated for the activity, regardless of the amount of time it took the physician to complete the activity.

 

Available Credit

  • 0.25 American Board of Internal Medicine (ABIM) MOC Part 2
    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
  • 0.25 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 0.25 Attendance
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Required Hardware/software

This activity works best in Google Chrome.