2025 CDI: General Documentation Education [IEM]

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Original Release Date: 06/30/2025
Expires: 06/30/2027

Credit claim for this activity will end at 11:59 PM 06/30/2027

Overview: 

Medicine is continually changing, including how to bill and how to document.  Unfortunately, education regarding how and what should be documented for accurate coding and billing is not something that is routinely educated upon until the provider is in the workforce. We know this because of the education we continually give to new as well as seasoned providers on proper documentation.  This module group gives providers a basic understanding of billing and provides an in-depth look at why documentation is important and how to achieve accurate documentation. Accurate documentation starts with the basics; an understanding of why it is important and then an understanding of how to document accurately. 

Commercial Support:
No commercial support was received for this activity.​​​​​​

Target Audience

Physicians, Specialty Physicians, Fellows, Residents,  Physician Assistants, Nurse Practitioners, Pharmacists across the system.

Learning Objectives

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

  • Demonstrate appropriate use of the hospital problem list
  • Explore the importance of accurate documentation and how incomplete documentation can lead to denials
  • Identify and document the appropriate principal diagnosis
  • Describe what social determinants of health are and how to appropriately document

 

Course summary
Available credit: 
  • 2.75 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 2.75 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.
  • 2.75 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.
  • 2.75 Attendance
Course opens: 
06/30/2025
Course expires: 
06/30/2027

Planners/Authors: 

  • Krysten Longoria - PA-C, CPC-A
  • Sunita Varghees, MD 
  • Sameera Vohra M.D.

Disclosure of Relevant Financial Relationships:
Each person in control of content has disclosed that she/he have no relevant financial relationships with companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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 2.75 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM MOC:  Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 2.75 MOC points in the American Board of Internal 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.

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

  • 2.75 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 2.75 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.
  • 2.75 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.
  • 2.75 Attendance
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