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Back to the Basics: Clinical Documentation of 5 Common Conditions

Back to the Basics: Clinical Documentation of 5 Common Conditions webcast image

  • ✓ Earn CEUs
  • 1.0 AAPC
  • 1.0 AHIMA

Get grounded in the basic pathophysiology of five frequently seen risk-adjusting medical conditions – altered mental status, Type II MI, respiratory failure, AKI and malnutrition – and elevate the quality of your clinical documentation integrity.

Price: $149.00

Product Code: AI021121

Webcast Format*:

Description Biography Continuing Education

They're five of the most common risk-adjusting medical conditions: altered mental status (encephalopathy or coma), type 2 myocardial infarction, respiratory failure, acute kidney injury and malnutrition. And yet, accurately diagnosing and documenting these conditions often proves to be highly elusive. The reasons vary, from providers who aren't clear about when to diagnose the condition in question, to coders and clinical documentation integrity (CDI) specialists who don't understand basic pathophysiology or recognize the clinical indicators.

This ICD10monitor webcast, featuring Dr. Erica Remer, offers a unique opportunity to get everyone — coders, CDI specialists and providers — on the same page. Using case examples to illustrate, Dr. Remer will walk you through the basic pathophysiology and clinical indicators of each condition, while dispelling common misconceptions. You'll also learn how to compose clear, compelling physician queries that lead to an accurate depiction of the patient.

Why This is Relevant:

Without a basic understanding of these five conditions, your coders and CDI specialists leave your organization vulnerable to payment denials and investigations. In addition, disconnects between clinical and documentation practices may lead to suboptimal quality metrics, potentially resulting in reimbursement penalties.

Don't leave these five important diagnoses to chance. Our webcast will impart indispensable basics to newer coders and CDI specialists, while more experienced individuals gain a refresher. Plus, get valuable tips for covering these topics with your providers.

Learning Objectives:

  • Distinguish among codable diagnoses manifested by altered mental status (specific encephalopathies and coma)
  • Know the differences between type 1 and type 2 myocardial infarctions and associate them with their etiologies
  • Identify the clinical indicators of respiratory failure, categorized by type and acuity
  • Recognize legitimate acute kidney injury from creatinine levels, compared to baseline
  • Be able to predict the likelihood of malnutrition and assess clinical validity when undernutrition diagnoses are documented

Who Should Attend:

Inpatient coding professionals, coding managers, coding auditing professionals, coding educators, and coding compliance staff; clinical documentation integrity specialists (CDISs), CDI physician advisors, and health information management (HIM) professionals, managers, directors and supervisors.

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