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