Clinical Documentation Integrity Certificate

Clinical Documentation Integrity (CDI) Program Overview
Clinical documentation improvement, or clinical documentation integrity, may be defined as a process by which clinical indicators, diagnoses, and procedures documented in the medical record are supported by the appropriate ICD-10-CM and ICD-10-PCS codes. Clinical documentation is at the core of every patient encounter. In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, timely, and legible to accurately reflect the patient's disease burden and scope of services provided.

Successful clinical documentation integrity (CDI) programs facilitate the accurate representation of a patient's clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, disease tracking and trending, and medical research.

The convergence of clinical care, documentation, and coding processes is vital to appropriate reimbursement, accurate quality scores, and informed decision-making to support high-quality patient care. CDI has a direct impact on patient care by providing information to all members of the care team as well as those who may be treating the patient at a later date.

Successful CDIPs should have a deep level of clinical knowledge in analyzing patient health records to provide assurance about the captured data from the physician and the coder to ensure accuracy in providing quality patient care. CDI also includes synergistically enhancing the quality of the hospital and the physician to better deliver their services. Physicians should be given an orientation on the role, strategies and methodologies applied by CDIC and be educated on annual DRG, CC, MCC, and HAC changes. This aids in embracing the communication between the physician and the CDI specialist. Setting strategies universally and investing more effort on the team can aid in improving CDI to become more effective and efficient, resulting in a higher quality of patient care and an exemplary healthcare system.

Objectives:
· Improve the quality and integrity of documentation
· Support patient care and improve clinical outcomes
• Identify documentation opportunities and collaborating with both clinical and coding staff
· Reflect each patient's severity of illness and complexity of care · Facilitate timely claim submission 
• Reduce denials by other organizations, RAC

This program offers unique content you can apply to your professional setting. The instructor will cover both inpatient and outpatient settings, creating an even larger return on investment for participants. You will learn about CDI best practices through real-life examples and assessment activities that draw from lesson-specific clinical and coding topics.

Training and Resources
Whether you are new to CDI, transitioning from a coding or clinical background, or an experienced CDI professional, this program will provide you education and resources to support your lifelong learning and continued advancement in clinical documentation improvement.

Training will be provided by AHIMA Approved Clinical Documentation Improvement Trainer and AHIMA Approved ICD-10-CM/PCS Trainer.  

Overview of CDI program and goals  

· MS-DRGs including CCs and MCCs and their impact on MS-DRG assignment The top 10 MS-DRGs for the organization 
· APR DRGs including Severity of Illness (SOI) and Risk of Mortality (ROM) The top 10 APR DRGs for the organization  
·  Hospital Acquired Conditions and their impact  
·  What documentation is used for code assignment and where to find in the paper and electronic medical record  
·  Review of clinical indicators for specific diagnosis such as respiratory failure and protein-calorie malnutrition        

Required Books:  ICD 10 book (latest edition)  

Instructor: AHIMA Approved CDI Trainer    

Eligibility Requirements for AHIMA'S CDIP EXAM: Candidates must meet one of the following eligibility requirements to sit for the CDIP examination: 

· Hold an associate's degree or higher; or
· Hold a CCS®, CCS-P®, RHIT®, or RHIA® credential

While not required, the following are recommended: 

· Minimum of two (2) years of clinical documentation integrity experience 

· Associate's degree or higher in a health care or allied health care discipline 

· Completion of coursework in the following topics:   Medical terminology  -    Human anatomy and physiology  -    Pathology  -    Pharmacology

Exam information can be found by clicking here: https://www.ahima.org/certification-careers/certification-exams/cdip/ 

Financial Assistance
When planning to attend a continuing education course or program, an important consideration is the cost, which may include tuition, books and travel. With Molloy College, Division of Continuing Education and Professional Studies, various financial assistance options are available to help students afford tuition. Since most Continuing Education courses do not lead to a college degree, they are not eligible for the traditional forms of financial aid, such as TAP and Pell. Some private lenders will help you finance continuing education and certificate programs. Click here to find out about student loans, re-training for those who are unemployed, employer and union vouchers and vocational services for individuals with disabilities. 

Free Career and Information Seminar:
If you are still undecided about the program or if you're unsure that this is even the right career for you, I would urge you to attend our free seminar, "Your Career in Clinical Documentation Integrity" which will be held January 2, 2025 from 6:00-7:00 p.m. online through Zoom. The speaker will offer real world advice about this career and talk about both the satisfactions and challenges of their chosen career. The career seminar is offered at no charge. However, you must register in advance to be able to login online. To R.S.V.P., click here or call 516.323.3550. You can also email us at conted@molloy.edu. 

Schedule of Classes

Tuition: $2,995

Registration:

Students should register for classes at least one week prior to the start of classes to insure enough time for you to get your confirmation and Zoom link. However, you can register up until the day of class. Please note that some of our classes do close out and some of our classes do cancel, so you may be taking a chance of not getting into the course of your choice by waiting.

Online registration is available by clicking here.  You will be able to pay for your classes online by ACH check or by MasterCard, Visa or Discover credit card. If you pay by credit card there will be a fee of 2.75% for domestic cards and 4.25% for international cards added to the tuition. You can avoid the credit card fee by paying with a check online.

Phone in registration is available by calling 516.323.3550 with your MasterCard, Visa or Discover credit card. There will be a credit card fee of 2.75% for domestic cards and 4.25% for international cards added to the tuition.

To register in person, by fax or mail, please follow the directions on our web page: www.molloy.edu/ce/registration under Registration.

Confirmation of your registration will be emailed to you upon receipt of your registration. Your Zoom link will be emailed to you shortly before the start date of you class if it was not included in your confirmation.

Questions? Contact Louis Cino at: lcino@molloy.edu.