The Clinical Documentation Improvement Specialist's Handbook, Second Edition

Get the guidance you need to make your CDI program the best there is

The Clinical Documentation Improvement Specialist's Handbook, Second Edition, is an all-inclusive reference to help readers implement a comprehensive clinical documentation improvement (CDI) program with in-depth information on all the essential responsibilities of the CDI specialist.

This edition helps CDI professionals incorporate the latest industry guidance and professional best practices to enhance their programs.  

Co-authors Heather Taillon, RHIA, and Marion Kruse, MBA, RN, combine their CDI and coding expertise to explain the intricacies of CDI program development and outline the structure of a comprehensive, multi-disciplinary program.

In this edition you will learn how to:

• Adhere to the latest government and regulatory initiatives as they relate to documentation integrity
• Prepare for successful ICD-10 transition by analyzing your CDI program
• Step up physician buy-in with the improved education techniques
• Incorporate the latest physician query guidance from the American Health Information Management Association (AHIMA)

Table of Contents

Chapter 1: Building the CDI Program
Chapter 2: CDI and the healthcare system
Chapter 3: Application of coding guidelines
Chapter 4: Compliant physician queries
Chapter 5: Providing physician education
Chapter 6: Monitoring the CDI program

What's new in the Second Edition?

Analysis of new industry guidance, including:

• AHIMA’s  “Managing an Effective Query Process” and “Guidance for Clinical Documentation Improvement Programs.”
• CMS guidance from new IPPS regulations, MLN Matters articles, Quality Improvement Organizations, and the Recovery Audit Contractor (RAC) program, among others
• Strategies to help you incorporate the guidance into your CDI program.

Tools to help you interpret MAC initiatives and RAC focus areas to enhance your CDI program and help prevent audit takebacks

New sample queries, forms, tools, and industry survey data

BONUS TOOLS!

This book also includes bonus online tools you can put to use immediately!

• Sample query forms
• Sample job descriptions for CDI managers, and CDI specialists
• Sample evaluation form for CDI staff
• Sample pocket guide of common documentation standards

Meet the Authors :

Marion Kruse, MBA, RN, is a director in the FTI Healthcare group of FTI’s Corporate Finance practice based in Atlanta. Kruse, an expert in Medicare regulations, provides education, project management and process improvement, targeting various severity adjusted DRG systems. She has implemented clinical documentation improvement programs for both small and large hospital systems.

Heather Taillon, RHIA, is the manager of coding compliance at St. Francis Hospital in Beech Grove, IN. She previously held various coding and supervisory roles in health information management and served as an original member of the ACDIS Advisory Board. She also served on the Indiana Health Information Management Association.

• Books

• Other Case Management Products
• Other Clinical Documentation Improvement Products
• Other Health Information Management Products