Apprentices progress at their own pace – they demonstrate
competency in skills and knowledge through assessment tests,
but are not required to complete a specific number of hours.
competency in skills and knowledge through assessment tests,
but are not required to complete a specific number of hours.
Clinical Document Improvement Specialist (CDIS)
AHIMA Foundation
Documents
View Original Document
Individual state requirements may vary. Please contact your local apprenticeship office to ensure this version is suitable to your state’s requirements.
Work Process Content
On the Job Training
Anonymous
Use reference resources for code assignment
0
Use reference resources for code assignment
0
Identify principal and secondary diagnoses in order to accurately reflect the patient's hospital course
0
Identify principal and secondary diagnoses in order to accurately reflect the patient's hospital course
0
Use coding software
0
Use coding software
0
Assign and sequence ICD-9-CM codes
0
Assign and sequence ICD-9-CM codes
0
Use coding conventions
0
Use coding conventions
0
Display knowledge of payer requirements for appropriate code assignments (e.g. Content Management Systems [CMS], All Patient Refined [APR], Ambulatory Patient [APG]
0
Display knowledge of payer requirements for appropriate code assignments (e.g. Content Management Systems [CMS], All Patient Refined [APR], Ambulatory Patient [APG]
0
Assign appropriate DRG Communicate with the coding/HlM staff to resolve discrepancies between the working and final DRGs
0
Assign appropriate DRG Communicate with the coding/HlM staff to resolve discrepancies between the working and final DRGs
0
Assign Current Procedural Terminology [CPT] and/or Healthcare Common Procedure Coding System [HCPCSI codes
0
Assign Current Procedural Terminology [CPT] and/or Healthcare Common Procedure Coding System [HCPCSI codes
0
Communicate with coding/HlM staff to resolve discrepancies in documentation for CPT assignment
0
Communicate with coding/HlM staff to resolve discrepancies in documentation for CPT assignment
0
Promote Clinical Documentation Improvement [CDI]
efforts throughout organization
0
Promote Clinical Documentation Improvement [CDI]
efforts throughout organization
0
Foster working relationship with CDI team members for reconciliation queries
0
Foster working relationship with CDI team members for reconciliation queries
0
Establish a chain of command for resolving unanswered queries
0
Establish a chain of command for resolving unanswered queries
0
Develop documentation improvement projects
0
Develop documentation improvement projects
0
Collaborate with physician champions to promote initiatives
0
Collaborate with physician champions to promote initiatives
0
Establish consequences for noncompliance to queries or lack of responses to queries in collaboration with providers
0
Establish consequences for noncompliance to queries or lack of responses to queries in collaboration with providers
0
Develop CDI policies and procedures
0
Develop CDI policies and procedures
0
Identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity
0
Identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity
0
Query providers in ethical manner to avoid potential fraud and/or compliance issues
0
Query providers in ethical manner to avoid potential fraud and/or compliance issues
0
Formulate queries to providers to clarify conflicting diagnoses
0
Formulate queries to providers to clarify conflicting diagnoses
0
Ensure provider query response is in the medical record
0
Ensure provider query response is in the medical record
0
Formulate queries to providers to clarify the clinical significance of abnormal findings identified in the record
0
Formulate queries to providers to clarify the clinical significance of abnormal findings identified in the record
0
Track Responses to queries and interact with providers to obtain query responses
0
Track Responses to queries and interact with providers to obtain query responses
0
Interact with providers to clarify Present On Admission [POA]
0
Interact with providers to clarify Present On Admission [POA]
0
Identify post-discharge opportunities that will affect Severity Of Illness [SOI], Risk Of Mortality [ROM], and ultimately, case weight
0
Identify post-discharge opportunities that will affect Severity Of Illness [SOI], Risk Of Mortality [ROM], and ultimately, case weight
0
Collaborate with the case management and utilization review staff to effect change in documentation
0
Collaborate with the case management and utilization review staff to effect change in documentation
0
Interact with providers to clarify Hospital Acquired Conditions [HAC]
0
Interact with providers to clarify Hospital Acquired Conditions [HAC]
0
Interact with providers to clarify the documentation of core measures
0
Interact with providers to clarify the documentation of core measures
0
Interact with providers to clarify Public Safety Indicators [PSI]
0
Interact with providers to clarify Public Safety Indicators [PSI]
0
Determine facility requirements for documentation of query responses in the record to establish official policy and procedures related to CDI query activities
0
Determine facility requirements for documentation of query responses in the record to establish official policy and procedures related to CDI query activities
0
Develop policies regarding various stages of the query process and time frames to avoid compliance risk
0
Develop policies regarding various stages of the query process and time frames to avoid compliance risk
0
Track denials and documentation practices to avoid future denials
0
Track denials and documentation practices to avoid future denials
0
Trend and track physician query response
0
Trend and track physician query response
0
Track working DRG (CDS) and coder final code
0
Track working DRG (CDS) and coder final code
0
Perform quality audits of CDI content to ensure compliance with institutional policies and procedures or national guidelines
0
Perform quality audits of CDI content to ensure compliance with institutional policies and procedures or national guidelines
0
Trend and track physician query content
0
Trend and track physician query content
0
Trend and track physician and query provider
0
Trend and track physician and query provider
0
Trend and track physician query volume
0
Trend and track physician query volume
0
Measure the success of the CDI program through dashboard metrics
0
Measure the success of the CDI program through dashboard metrics
0
Compare institution with external institutional benchmarks
0
Compare institution with external institutional benchmarks
0
Track data for CDI benchmarking and trending
0
Track data for CDI benchmarking and trending
0
Track data for specialty benchmarking and trending
0
Track data for specialty benchmarking and trending
0
Use CDI data to adjust departmental workflow
0
Use CDI data to adjust departmental workflow
0
Articulate the implications of accurate coding
0
Articulate the implications of accurate coding
0
Educate providers and other members of the healthcare team about the importance of the documentation improvement program and the need to assign diagnoses and procedures when indicated, to their highest level of specificity
0
Educate providers and other members of the healthcare team about the importance of the documentation improvement program and the need to assign diagnoses and procedures when indicated, to their highest level of specificity
0
Articulate the implications of accurate coding with respect to research, public health reporting, case management and reimbursement
0
Articulate the implications of accurate coding with respect to research, public health reporting, case management and reimbursement
0
Monitor changes in the external regulatory environment in order to maintain compliance with all applicable agencies
0
Monitor changes in the external regulatory environment in order to maintain compliance with all applicable agencies
0
Educate the staff on the clinical documentation improvement program including and ethical documentation practices
0
Educate the staff on the clinical documentation improvement program including and ethical documentation practices
0
Develop educational materials to facilitate documentation that supports severity of illness, risk mortality, and utilization of resources
0
Develop educational materials to facilitate documentation that supports severity of illness, risk mortality, and utilization of resources
0
Research and adapt successful best practices within the CDI specialty that could be utilized at one's own organization
0
Research and adapt successful best practices within the CDI specialty that could be utilized at one's own organization
0
Apply regulations pertaining to CDI activities
0
Apply regulations pertaining to CDI activities
0
Consult with compliance and HIM department regarding legal issues surrounding CDI efforts
0
Consult with compliance and HIM department regarding legal issues surrounding CDI efforts
0
Related Instruction Content
Training Provider(s):
860
RI hours
Medical Terminology
45
Medical Terminology
45
Anatomy and Physiology
45
Anatomy and Physiology
45
Pathophysiology
30
Pathophysiology
30
Pharmacology
15
Pharmacology
15
Reimbursement/Revenue Cycle
45
Reimbursement/Revenue Cycle
45
Legal and Compliance
45
Legal and Compliance
45
Health Information and Delivery Systems
45
Health Information and Delivery Systems
45
Health Record and Data Content
90
Health Record and Data Content
90
Coding Classification
90
Coding Classification
90
Health Information Systems
90
Health Information Systems
90
Principles of Research
45
Principles of Research
45
Statistics
45
Statistics
45
Healthcare Human Resource Management
45
Healthcare Human Resource Management
45
Quality Improvement
45
Quality Improvement
45
Project Management
45
Project Management
45
Leadership
45
Leadership
45
Data Analysis
45
Data Analysis
45