Pediatric CDI Essential Skills

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Pediatric CDI Essential Skills

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Pediatric CDI Essential Skills

This one-of-a-kind course offers those interested in expanding their clinical documentation (CDI) improvement efforts into pediatric and children's concerns an in-depth look at the nuances of clinical conditions and coding rules governing this unique patient population. Children's conditions can be much more complex than those faced by adults and they come with very specific diagnostic evaluations that CDI professionals need to know in order to query effectively, win physician's trust, and ensure the appropriate story about their tiny patients' care gets captured accurately.

Course Objectives:

At the conclusion of this educational activity, participants will be able to:

  • Explain differences in coding rules related to common childhood diagnoses
  • Identify clinical indicators related to specific diseases
  • Develop processes for effective medical record review processes for pediatric populations
  • Create compliant queries related to conditions frequently seen in children's hospitals

Contributor Bios:

Karen Bridgeman, MSN, RN, CCDS, has been a Clinical Documentation Specialist for over nine years, and is currently the CDI Educator for the Medical University of South Carolina.  In 2012, she developed and implemented the successful Pediatric CDI Program at the Medical University of South Carolina’s Children’s Hospital.    She is a frequent contributor on pediatric subject matter for the ACDIS Journal as well as a presenter at the ACDIS National Conferences.  She currently serves on ACDIS’s CCDS Certification Board.

Audience:

  • Clinical documentation improvement specialists
  • CDI program managers
  • Coders
  • Those working in pediatric units or childrens' hospitals

Coding and Payment System Overview

In this module, we’ll review the fundamental role and responsibilities of clinical documentation improvement (CDI) specialists and discuss the complicated coding and payment systems related to pediatric treatment.

Upon completion of this module, participants will be able to:

  • Discuss the role of the pediatric CDI specialist
  • Describe the inpatient prospective payment system (IPPS)
  • Discuss the ICD-10-CM/PCS code set
  • Demonstrate an understanding of the MS-DRG system


APR-DRG Classification System

In this module, we’ll review the various ways government and private payers group ICD-10-CM/PCS codes into buckets representing similar resource use and risk to patient health outcomes. These grouping systems are often complex and sometimes proprietary.

Upon completion of this module, participants will be able to:

  • Compare the differences between the APR-DRG and the MS-DRG systems
  • Discuss the impact of documentation on severity of illness (SOI) and risk of mortality (ROM)
  • Discuss the clinical applications of the APR-DRG in common pediatric conditions
  • Identify common secondary conditions that impact SOI and ROM


Conducting the Pediatric Health Record Review

In this module, we'll discuss the steps required to effectively review the medical record including identifying the differences between various review timelines and which areas of the medical record to examine at which points during the patients' stay.

Upon completion of this module, participants will be able to:

  • Identify whose documentation can be used for coding a health record
  • Discuss the difference between a concurrent review, a follow-up review, and a back-end review
  • Describe how to prioritize concurrent health record reviews
  • Demonstrate the steps to conduct a health review


Coding Guidelines and APR-DRG Concerns in the Newborn and Neonatal Population

In this modules, we'll discuss the rules governing documentation and coding for newborns and neonates particularly those located in Guidelines for Coding and Reporting found in Chapter 16 of the code set pertains to Certain Conditions Originating in the Perinatal Period.

Upon completion of this module, participants will be able to:

  • Discuss the ICD-10-CM Official Guidelines for Coding and Reporting FY 2019 Chapter 16: Certain Conditions Originating in the Perinatal Period
  • Discuss the clinical application of the APR-DRG classification system on common neonatal conditions
  • Identify common secondary conditions that impact the severity of illness and risk of mortality in the neonatal population


Respiratory Conditions

In this module, we’ll review the common respiratory conditions afflicting the neonatal and pediatric populations and opportunities related to clinical documentation improvement.

Upon completion of this module, participants will be able to:

  • Identify clinical indicators for respiratory failure in the pediatric population
  • Discuss common newborn and pediatric respiratory conditions
  • Identify secondary diagnoses related to pediatric respiratory conditions
  • Develop compliant query for pediatric respiratory conditions


Congenital Cardiac Conditions

In this module, we’ll review the wide variety of congenital cardiac conditions principally looking to define the clinical pathophysiology clinical documentation specialists need to know to analyze the information in the medical record and identify opportunities for clarification.

Upon completion of this module, participants will be able to:

  • Describe the complex anatomy of common congenital heart defects.
  • Discuss the complexities of various congenital heart defects for accurate code assignment in ICD-10.
  • Identify documentation needs related to congenital heart defects.
  • Develop query opportunities for secondary diagnoses in congenital heart defect.


Other Pediatric Conditions

In this module, we’ll review other common conditions affecting the pediatric populations and opportunities related to clinical documentation improvement such as cerebral palsy, developmental delays, seizures, malnutrition, and abuse.

Upon completion of this module, participants will be able to:

  • Discuss various pediatric conditions
  • Understand coding guidelines related to pediatrics
  • Identify secondary diagnoses related to various pediatric conditions
  • Identify query opportunities for various pediatric conditions


Final Exam

Continuing Education

American Nurses Credentialing Center (ANCC)
HCPro is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Comission on Accreditation.
This educational activity for 6.5 nursing contact hours is provided by HCPro.

Association of Clinical Documentation Improvement Specialists (ACDIS)
This program has been approved for 6.5 continuing education units towards fulfilling the requirements of the Certified Clinical Documentation Specialist (CCDS) certification, offered as a service of the Association of Clinical Documentation Improvement Specialists (ACDIS).

American Health Information Management Association (AHIMA)
This program has been approved for 6.5 CE credits for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA).

Terms

The term for the full library is 1 year. The term for single courses is 180 days.