Title: Module 3 Instructions
Course: HIM 3620 - TAACCCT Grant > Section: Module 3 - Translation of Clinical Documentation into Coded Data

Readings

- Chapters 3 and 4
- Clinical Documentation Guidance article
- INSTRUCTOR: Insert "Creating a Query" article from the AHIMA Body of Knowledge Library

Lecture

PowerPoint: ICD-10-CM/PCS for CDI. The PowerPoint presentation created by AHIMA for HIM professionals in the role of CDI to create an understanding and provide high-level overview of ICD-10-CM/PCS.

It is imperative that correct code assignments are given based on patient documentation.  As ICD-10-CM requires descriptive documentation, the CDI specialist plays an inherent role.  Please review the AHIMA Practice Brief which outlines documentation guidance for accurate code assignments in ICD-10-CM/PCS.

Focusing on clinical documentation improvement should be a key initiative for organizations and providers during this extended period of transition to the ICD-10-CM/PCS code set. Through accurate documentation, coded data can be utilized to make insightful decisions regarding patient treatment, care plans, and strategic decisions. Collaborative insight and support for CDI can result in more detailed, accurate, and higher-quality data, which in turn leads to improved quality reporting, better clinical decision support, and improved patient safety.

Assignment

Chapters 1-4 Quiz