A guide to improving clinical documentation in a changing health environment
The fourth edition of this trusted resource helps a practice uncover where payment may be slowing or missing while ensuring compliance with payer rules and coding policy. Readers will come to understand how to identify overcoding and undercoding, improve documentation, and develop compliance improvement programs.
This publication will allow readers to:
- Analyze and review documentation guidelines and elements for each level of service
Understand the medical record review process
- Comprehend how to properly audit the medical record
- Analyze and report results of an audit
- Develop mechanisms for reporting and educating staff on proper reporting
- Prepare for credentialing exams
Features and Benefits
- Chapter dedicated to clinical documentation improvement
- Case studies, featuring scenarios across nine different specialties for the office and hospital
- Checkpoint exercises and chapter-ending quizzes
- Audit cases, including surgery and radiology
- Tips on auditing and documentation
- Glossary of related terminology
- Downloadable user-friendly tools, including audit tools, audit exercises with case studies and answer keys, and an extensive PowerPoint presentation
Target Audience
Coding professionals, medical record auditors, academic and organizational educators, medical insurance specialists, clinical document improvement specialists, medical staff, practice administrators, consultants, independent billing and reimbursement personnel, physicians and physician leaders in practice and hospital settings
About the Author
Deborah J. Grider, CPC, COC, CPC-P, CPC-1, CEMC, CPMA, CCS-P, CDIP, is a nationally recognized health care consultant. She teaches and consults with private practices, physician networks, and hospital-based educational programs. Deborah audits medical records and provides clinical documentation improvement implementation guidance for physician practices.
She conducts many seminars and workshops throughout the year on coding and reimbursement issues. She is the former program director of the Medical Coding Program for IU Health.
About the Publisher
The American Medical Association has promoted scientific advancement, improved public health and protected the patient-physician relationship since its establishment in 1847. The AMA is the premier national organization dedicated to empowering the nation's physicians to provide safer, higher quality and more efficient care to patients and communities.
For more information on the AMA, please visit ama-assn.org.
For more than 50 years, the AMA, in drawing upon its deep expertise and resources, has authored and published books, data files and online resources that answer the needs of today's busy physicians and their staff. The AMA product line includes titles on CPT®, HCPCS and ICD-10 coding, as well as reimbursement, practice management, disability evaluation, impairment, HIPAA and electronic health records. For more information on all AMA products, please visit amastore.com.