A faster, easier pathway to high-quality documentation
High-quality clinical documentation plays an essential role in getting paid correctly and improving patient outcomes. Our clinical documentation integrity (CDI) book measures up to this critical function, using a three-step approach that covers possible clinical indicators, risk factors and treatments, enabling effective chart reviews and physician queries. Divided into major diagnostic categories (MDCs), this convenient handbook integrates coding rules and guidelines, DRG assignments, breakdowns of ICD-10 codes and high-risk DRGs. In addition, solidify your knowledge through case studies, anatomy and physiology lessons, at-a-glance reference aids, diagrams and much more. It’s the ideal training tool for both new and seasoned CDI specialists!
Features and Benefits
Clear, step-by-step guidance tailored to busy professionals:
- Divided into MDCs in DRG layout, for the fastest, easiest navigation of any CDI how-to resource on the market
- Comprehensive anatomy and physiology lessons in every chapter, topped off with discussions of documentation and coding
- Coding guidelines and tips, plus AHA coding clinic references and a breakdown of ICD-10 codes into an easy-to-learn format
- Case studies drawn from actual documentation, with questions and answers — a great tool for testing CDI competency
- Guidance with implementing a CDI program and measuring its effectiveness
- Discussion of laboratory values and quality/risk management issues
- Numerous at-a-glance learning and reference aids, including charts/diagrams for knowing when to initiate physician queries and tracing documentation to the appropriate codes
- Searchable format (PDF version) for quickly finding answers to questions
Updated and expanded content, including:
- Clarifies coding issues for COVID diagnosis, ongoing symptoms and recovery
- Incorporates MS-DRG changes, based on the IPPS final rule, throughout the book; includes OR designation shifts
- Updated with all new CC/MCCs and CC/MCC shifts
- Revised and updated information and guidance specific to new ICD-10-CM/PCS codes
- Details on the new classification of pressure ulcers
- Guidance with social determinants of health and the ramifications for CDI staff
- Enhanced comprehensive MS-DRG tables, enabling faster identification of current DRG mix, potential opportunities and the latest changes
**Please note that eBooks cannot be printed, and all sales on eBooks are final. If you would like a printed copy of this resource please select the Print version and allow time for shipping.
Foundations of Clinical Documentation Integrity
- What is CDI?
- Symptoms vs. Diagnoses
- MDCs and MS-DRGs
- The Grouper
- Principal and Secondary Diagnoses
- Defining SOI and ROM
- Case-Mix Index (CMI) and Base Reimbursement Rate
- Whose Documentation Counts?
- Daily Documentation
Diagnosis Guidelines
- Principal Diagnosis Guidelines
- Secondary Diagnoses Guidelines
ICD-10 Guidelines
- Understanding Coding and Your Coding Resources
- Building ICD-10 Codes
Performing New Patient and Follow-Up Reviews
- New Patient Reviews
- Prioritizing New Patient Reviews
- Follow-Up Reviews or Additional Reviews
Queries: A Tool for CDI Success
- Who Should Send Queries?
- What is a Query?
- A Three-Step Approach
- What’s the Best Practice for Sending Queries?
- What Should You Include in the Query?
- Diagnostic Options of a Query
- What is the Impact of Your Query?
- What are Possible Query Impacts?
- Examples of Compliant Queries
INTRODUCTION TO CDI Metrics
Connecting with Physicians and Providers
- Introducing Yourself
- Education, Education, Education
- Physician Champion or Advisor
Pepper Report
- How Can the PEPPER Report Assist You with RA Activity?
FY 2022 Final Hospital-Acquired Conditions (HACs)
Introduction to MDCs and MS-DRGs
MDC 1: Diseases and Disorders of the Nervous System
- MDC 1: Severity Drivers, CCs, and MCCs
- MDC 1: Case Studies
MDC 4: Diseases and Disorders of the Respiratory System
- Pneumonia
- Respiratory Failure
- Postoperative Respiratory Failure
- Obesity Hypoventilation Syndrome
- Pleural Effusion
- Pulmonary Embolus
- Cystic Fibrosis
- Asthma
- MDC 4: Severity Drivers, CCs, and MCCs
- MDC 4: Case Studies
MDC 5: Diseases and Disorders of the Cardiovascular System
- Chest Pain
- Angina
- Acute Myocardial Infarction
- Cardiorenal Syndrome
- Arrhythmias
- Deep Vein Thrombosis
- Pericarditis
- Acute Cor Pulmonale
- Shock (Specified)
- Cardiac Catheterization
- MDC 5: Severity Drivers, CCs, and MCCs
- MDC 5: Case Studies
MDC 6: Diseases and Disorders of the Digestive System
- Abdominal Pain
- GI Bleed
- GI Malignancy
- Gastroparesis
- Intestinal Obstruction and Lysis of Adhesions
- MDC 6: Severity Drivers, CCs, and MCCs
- MDC 6 Case Studies
MDC 7: Diseases and Disorders of the Hepatobiliary System and Pancreas
- Defining Underlying Cause
- Cirrhosis
- Hepatic Encephalopathy
- Shock Liver
- MDC 7: Severity Drivers, CCs, and MCCs
- MDC 7 Case Studies
MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue
- Back Pain
- Fractures
- Pathologic Fractures
- Hungry Bone Syndrome
- Rhabdomyolysis
- Orthopedic Procedures In ICD-10
- MDC 8: Severity Drivers, CCs, and MCCs
- MDC 8 Case Studies
MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast
- Pressure Ulcers/Injuries
- Cellulitis and Complex Wounds
- Debridement Documentation
- MDC 9: Severity Drivers, CCs, and MCCs
- MDC 9 Case Study
MDC 10: Endocrine, Nutritional and Metabolic Diseases and Disorders
- Diabetes
- Body Mass Index (BMI): Underweight and Obesity
- Malnutrition
- MDC 10: Severity Drivers, CCs, and MCCs
- MDC 10 Case Studies
MDC 11: Diseases and Disorders of the Kidney and Urinary Tract
- Understanding the Kidneys
- Urinary Tract Infection
- MDC 11: Severity Drivers, CCs, and MCCs
- MDC 11 Case Studies
MDCs 12 and 13: Diseases and Disorders of the
- Male and Female Reproductive Systems
- MDCs 12 and 13: Severity Drivers, CCs, and MCCs
MDC 14: Pregnancy, Childbirth, and the Puerperium
MDC 15: Newborns and Other Neonates with Conditions
- Originating in the Perinatal Period
- MDC 15: CCs and MCCs
MDC 16: Diseases and Disorders of the Blood and Blood-Forming Organs and Immunological Disorders
- Anemia
- Pancytopenia
- Neutropenic Fever
- Coagulopathy and DIC
- MDC 16: Severity Drivers, CCs, and MCCs
- MDC 16 Case Studies
MDC 17: Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms (Cancer)
- Cancer Coding Guidelines
- Query Opportunity—Cancer Patients
- MDC 17: Severity Drivers, CCs, and MCCs
- MDC 17 Case Study
MDC 18: Infectious and Parasitic Diseases, Systemic or Unspecified Sites
- Sepsis
- MDC 18: Severity Drivers, CCs, and MCCs
- MDC 18 Case Studies
MDC 19: Mental Diseases and Disorders
MDC 20: Alcohol/Drug Use and Alcohol/Drug-Induced
- Organic Mental Disorders
- MDC 19 and 20: Severity Drivers, CCs, and MCCs
- MDC 19 and 20 Case Studies
MDC 21: Injuries, Poisonings, and Toxic Effects of Drugs
(frequently called “The Complications Chapter”)
- Complications of Treatment
- Poisonings/Adverse Reactions
- MDC 21: Severity Drivers, CCs, and MCCs
- MDC 21 Case Study
MDC 22: Burns
- Burns
- MDC 22: Severity Drivers, CCs, and MCCs
- MDC 22 Case Study
MDC 24: Multiple Significant Trauma
- MDC 24: Severity Drivers, CCs, and MCCs
- MDC 24 Case Study
MDC 25: HIV Infections
- HIV and AIDS
- MDC 25: Severity Drivers, CCs, and MCCs
- MDC 25 Case Studies
High-Risk MS-DRGs Table
Hierarchical Condition Categories (HCCs)
Lab Value Breakdown
- Understanding the Significance of Lab Values
- Documented Lab Values with Clinical Significance
Final Test and Comprehensive Case Studies
- Comprehensive Case Studies
Answers to Final Test and Comprehensive Case Studies
Appendix A: 2022 MS-DRGs, Weights, Mean LOS and Estimated Payments
References
