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Core Courses
Medical Coding – Physician/ProFee Based (PBC)
Medical Coding – Facility/Outpatient Based (FBC)
Medical Coding – Inpatient Based (IPC)
Medical Coding – Risk Adjustment (RAC)
Medical Billing – Physician / Office Based (PBB)
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Pathophysiology (PATHO)
Pharmacology (PHARM)
ICD-10-CM (I10CM)
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Specialty Coding – Home Health (SC-HH) — Coming Soon
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Medical Coding – Facility/Outpatient Based – Review Blitz (FBC-RB)
Medical Coding – Inpatient Based – Review Blitz (IPC-RB)
Medical Coding – Risk Adjustment – Review Blitz (RAC-RB)
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Medical Coding – Facility/Outpatient Based – Practice Exam (FBC-PE)
Medical Coding – Inpatient Based – Practice Exam (IPC-PE)
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Medical Billing – Physician / Office Based – Practice Exam (PBB-PE)
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←
Back to All Clinical Documentation Guides
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CDI Textbook
⚊
▶
Ch 1 – Intro to CDI
Overview of CDI
Importance and Impact of CDI
Role of the CDI Specialist
Key Concepts in CDI
The Future of CDI
▶
Ch 2 – Roles & Competencies
Learning Objectives
Overview
Differentiating Inpatient & Outpatient CDI
Knowledge Requirements by Setting
Core Skills and Knowledge Areas
Summary: Key Takeaways
Discussion Questions and Reflection
References
▶
Ch 3 – Ethics & Compliance
Learning Objectives
Overview
Core Elements of Professionalism
ACDIS Code of Ethics
AHIMA Ethical Standards
Regulatory Compliance Framework
ACDIS/AHIMA Query Standards
Common Ethical Dilemmas
Interdisciplinary Collaboration
Summary: Key Takeaways
Discussion Questions
▶
Ch 4 – Medical Record Review
Learning Objectives
Overview
Components of the Medical Record
Inpatient Documentation
Outpatient Documentation
Chapter Summary
▶
Ch 5 – Regulations & Reimbursement
Overview of Healthcare Regulations
Reimbursement Systems
The Role of CDI in Reimbursement
▶
Ch 6 – Anatomy & Pharmacology
Overview
Learning Objectives
Understanding Major Diagnostic Categories
Why MDCs Matter for CDI Specialists
Major Diagnostic Categories: Detailed Clinical Review
MDC 01: Nervous System
MDC 04: Respiratory System
MDC 05: Circulatory System
MDC 06: Digestive System
MDC 10: Endocrine & Metabolic
MDC 11: Kidney & Urinary Tract
MDC 18: Infectious Diseases
Medication Documentation & Pharmacology
Diagnostic Testing & Clinical Indicators
Common Documentation Pitfalls
Key Points
Review Questions
Practical Exercises
▶
Ch 7 – CDI Review Processes
Overview
Understanding Query Types
Query Formats
Principles of Non-Leading and Compliant Queries
Clinical Indicators Required for Queries
Query Timing and Response Management
Documentation of Provider Responses
Common Pitfalls and Best Practices in Querying
Summary and Key Takeaways
Review Questions
Case Study Exercise
▶
Ch 8 – Provider Query Process
Overview
Inpatient Concurrent Review
Inpatient Retrospective Review
Outpatient Prospective Review
Outpatient Retrospective Review
Understanding Medical Decision Making in Outpatient CDI
Challenges in Outpatient CDI Due to Encounter Duration
Use of Technology and EHR Tools in CDI Reviews
Integrating Prior Encounter Information
Monitoring and Auditing Queries and Reviews
Key Points
Review Questions
Case Exercise: Inpatient Concurrent Review
Case Exercise: Outpatient Retrospective Review
Case Exercise: Medical Decision Making Assessment
▶
Ch 9 – Risk Adjustment
Chapter Overview
Understanding Risk Adjustment Fundamentals
Hierarchical Condition Categories: Structure and Function
Risk Adjustment Factor Score Calculation
Documentation Requirements for Risk Adjustment
Differences in Risk Adjustment: Inpatient vs. Outpatient Settings
Common Pitfalls in Risk Adjustment Documentation
Best Practices for CDI Risk Adjustment Programs
Key Points
Review Questions
Practical Exercise: Risk Adjustment Documentation Analysis
References
▶
Ch 10 – Program Management
Chapter Overview
Understanding CDI Program Management
Program Metrics and Performance Indicators
Data Collection, Tracking, and Reporting Tools
Benchmarking and Performance Improvement
Provider Education and Engagement Strategies
Aligning CDI Programs with Organizational Goals and Compliance
Integrating Inpatient and Outpatient CDI Metrics
Key Points
Review Questions
Case Study Exercise
▶
Ch 11 – Quality Reporting
Chapter Overview
Understanding Quality Metrics in Healthcare
The Hospital Value-Based Purchasing Program
Patient Safety Indicators
Hospital-Acquired Conditions
Quality Reporting Methodologies
CDI Contribution to Quality of Care and Outcomes
Quality Documentation in Outpatient Settings
Key Points
Review Questions
Case Study: Analyzing Quality Documentation Gaps
▶
Ch 12 – Special Topics
Overview
Documentation and Coding of Complex Clinical Conditions
Handling Documentation in Mental Health, Substance Use, and Rare Diseases
Integration of Pharmacology and Diagnostic Tests in CDI
Addressing Chronic Conditions in Outpatient Settings
Use of Artificial Intelligence and Automation in CDI
Key Points
Review Questions
Practical Exercise: Complex Case Documentation Review
References
Clinical Doc Guides
⚊
Abortions
Adjuvant Therapy
Anxiety
Aortic Aneurysm
Burns
Sickle-Cell Disease
Cleft Lip/Palate
Congenital vs Acquired
COPD
Crohn's Disease
Depression
Diabetes
Isoimmunization
Jaundice
Manifestations/Sequelae
Meckel's Diverticulum
Multiple Gestations
Neoplasms
Tympanic Perforations
Peripheral Vascular
Pneumonia
Polydactyly/Syndactyly
Pre-Term Labor
Pressure Ulcers
Pulmonary Fibrosis
Venous Stasis Ulcers
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