Bridging The Gap: Clinical Documentation And Coding


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Course Description

Earn 3 CEUs from Practice Management Institute

This course is designed to help coders work with providers to assess and gather the information needed in documentation to support appropriate code assignments. Class content is relevant for medical office professionals responsible for accurate medical coding and billing in an outpatient healthcare setting.

Coders are the caretakers of complete reimbursement in a value-based era. Do your skills measure up?

  • How effective are you at querying providers to extract complete and correct information from the documentation, i.e., “all of these words have to be in the documentation”?
  • Do you understand 7th character usage and difference between initial and subsequent?
  • Can you identify all the documentation components that are necessary for complete reimbursement?
  • Can you identify all the components necessary in the documentation to code to the highest degree of specificity?
  • Do you know the dangers of missed revenue, denials, and audit risks with punitive consequences?

Key Highlight of The Session:

This course will help coders work with providers to assess and gather the information needed in documentation to support appropriate code assignments.

  • Review of clinical documentation requirements for ICD-10
  • Identify problems with clinical documentation
  • Provide strategies for maintaining effective communication and positive professional interaction between clinicians and coders
  • Focus on the documentation impact of patient quality care
  • Learn how quality reporting relates to clinical documentation
  • Establish guidelines for coding of medical records to their greatest level of specificity
  • Relay the value of ongoing performance measurement and support
  • Review common clinical documentation problems

Target Audiences:

  • Coders
  • Auditors
  • Billers
  • Physicians
  • Mid-Level Providers
  • CDI Specialists
  • Consultants
  • Office Managers
  • Administrators

Meet The Presenter:

Pam Joslin, MM, CMC, CMIS, CMOM, CMCO, CEMA has more than 20 years of medical practice management, coding, reimbursement and compliance experience. She has managed medical practices ranging from single to multi-specialty groups, including an ASC. She is an advocate of process improvement and empowering employees to bring about the “best practice” results for their organization. Ms. Joslin maintains memberships in professional organizations to support her continuing cycle of learning in the ever-changing healthcare industry. In 2014 she joined the faculty of Practice Management Institute (PMI) ® – a leading provider of continuing education for medical office professionals. Prior to joining the PMI Instructor team, Pam was an Adjunct Instructor and served on three advisory boards at a community college in San Antonio, Texas.

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