Diabetes Mellitus Documentation [IEM]
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Overview: Diabetes Mellitus 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.
Providers are documenting an unspecified diabetic patient when they are actually treating and managing a diabetic patient with hyperglycemia and several diabetic complications. Therefore, there is not an accurate reflection of the severity of illness of their patients and the higher level of care needed to treat and manage the patient’s diabetic conditions. A separate issue was also that diabetes was incorrectly being added to the diabetic registry due to provider documentation
This module is designed to help providers understand the Clinical Documentation Improvement (CDI) Program. Through examples and interactive exercises, the learner will be exposed to the key components of CDI as well as various Quality metrics.
Physicians and Advanced Practice Providers and Residents of the Baylor Scott & White Health System
After participating in this activity, the learner should be able to:
For further study:
Planners/Authors: This activity was planned, reviewed, edited, and approved for use as the curriculum for the Baylor Scott & White Health organization by:
Yoon Sim Kim, DO, CCDS
Inpatient Clinical Documentation Physician Lead
Adjunct Assistant Professor at TAMU College of Medicine
Dr. Elizabeth Aguirre, MD
Clinical Documentation Improvement Program
Inpatient Clinical Documentation Physician Lead
Krysten Longoria, PA-C
Sameera Vohra, MD
Elizabeth Aguirre, MD
Planners/Authors for this enduring material,,as listed above, have no relevant financial relationship(s) to disclose with companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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.
- 0.50 American Board of Internal Medicine (ABIM) MOC Part 2Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.50 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.
- 0.50 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.
- 0.50 Attendance