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Catalog and Student Handbook 2019-2020

CDI 2010 Record Review and Clinical Coding Practice

This course will focus upon review of medical record cases, the discussion of opportunities for documentation improvement of diagnoses and procedures regarding their level of specificity and presence on admission. It will also focus on the review of queries regarding potential fraud and/or compliance issues, conflicting diagnoses, abnormal findings, and post-discharge query opportunities. Review of requirements for documentation of query response and tracking of queries will also be studied. Students will develop policies for documentation of query responses in the record to establish official policies and procedures related to CDI query activities as well as develop policies regarding various stages of the query process and time frames to avoid compliance risk. Using coding software, the student will assign and sequence diagnostic and procedural codes following all coding conventions and with consideration of payer requirements for appropriate code assignment and assign appropriate DRG codes.