The Outpatient CDI Specialist’s Complete Training Guide

Tracy Boldt, RN, BSN, CCDS, CDIP, and Ellen Jantzer, RN, MSN, CCDS, CCS, CRC

Fast-track your outpatient CDI efforts by effectively onboarding new staff

Starting an outpatient CDI program from scratch can prove daunting: Its mission, focus, structure, and support all need to be defined, and on top of that, the program must be staffed. Your new hires will need orientation, training, and help understanding the core skills of a CDI professional—in addition to specialized training on outpatient coding, billing, and record reviews. What you don’t need to worry about, though, is creating training materials from scratch.

Working from the acclaimed Clinical Documentation Improvement Specialist’s Complete Training Guide, long-time ACDIS members and experienced outpatient CDI program directors have adapted that celebrated text to delve into the complexities of CDI in the physician practice setting. The Outpatient CDI Specialist’s Complete Training Guide serves as a bridge between your new CDI specialists’ first day on the job and their first effective steps reviewing physician practice records. This book is the perfect resource for CDI program managers to help new CDI professionals understand their roles and responsibilities.

This training guide provides:

• An introduction for managers, with suggestions for training staff and guidance for manual use
• Sample training timelines
• Test-your-knowledge questions to reinforce key concepts
• Case study examples to illustrate essential CDI elements
• Documentation challenges associated with common diagnoses found in the physician practice setting
• Sample policies and procedures

Published: August 2018

Page count: 160
Dimensions: 8x5, spiral bound
ISBN: 978-1-68308-803-5

Table of Contents

CDI Specialist Roles and Responsibilities
Outpatient Coding

• ICD Origins and Transitions
• Additional Coding Guidance
• Current Procedure Terminology
• E/M 101
• Risk-Adjustment Methods
• Hierarchical Condition Categories

Reimbursement Systems

• Government and Private Payers
• Compliant Query Practices
• Regulatory Oversight
• The Art of Record Review
• Documentation Improvement Opportunities
• Physician Education

Evaluating Success

• Peer Reviews
• Productivity and Other Metrics
• Identify Program Targets

Online Materials

• Sample Orientation Schedule
• Sample Mentor and Preceptor Roles
• Sample CDI Outpatient Job Description
• Sample Orientation Checklist
• Record Review Checklists
• Physician Education Discussion Scenarios
• Sample Auditing Checklist
• Test Your Knowledge Questions and Answers