Learning Objectives
1. Explain the steps to overcome issues that prevent the clinical
documentation improvement process from being effective in a facility
2. Analyze the results of an audit of internal medicine charges
Reading and Resources
Textbook: Healthcare Code Sets, Clinical Terminologies, and Classifications
Systems, Introduction and Chapters 1 and 2
Introduction
This very short reading will examine the core elements needed to
understand coding and classification systems.
Chapters 1 and 2
This reading will give greater detail on the diagnosis codes and procedure
codes that you will be using to perform the audits in the course.
PDF: Evaluation and Management Services Guide
This document will provide the necessary guidelines to properly apply codes
to the medical documentation that will be reviewed.
This resource supports this module’s case study claim. Use this information
as support for changing the codes that were originally billed.
Article: Your hospital's medical staff bylaws may be creating undue medical
staff burden — here's why
This article discusses medical staff bylaws and the importance of updating
them in order to achieve continual improvement in the hospital setting. This
article supports this week's discussion.
