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Clinical Documentation Improvement, Certificate (Online)

Overview

Labouré College’s Clinical Documentation Improvement Certificate program (CDI) is offered 100% online. The program includes two courses and can be completed in one semester. The College’s CDI certificate prepares students for both national exams, the CDIP from AHIMA and CCDS from ACDIS, to earn the credentials of Certified Documentation Improvement Practitioner and Certified Clinical Documentation Specialist.

Program Outcomes

  1. Formulate compliant, collaborative queries to providers to clarify conflicting or non-specific diagnoses
  2. Identify opportunities to collaborate with the case management and utilization review staff to affect change in documentation
  3. Demonstrate appropriate places in the medical record from which diagnoses can be assigned.
  4. Explain which types of physician documentation (i.e., RN, PA, and NP) can be used to assign diagnoses.
  5. Use coding software. Assign and sequence ICD-10 and CPT codes.
  6. Explain how CMS selects certain diagnoses as a CC or MCC.
  7. Explain the clinical indicators and query opportunities related to each Major Diagnostic Category (MDC).
  8. Explain how to assign a correct diagnosis when two or more diagnoses are coequal to admission.
  9. Define which conditions are considered hospital-acquired conditions by CMS.
  10. Explain how to assign a working DRG when a patient has multiple diagnoses in play.
  11. Develop tracking tools for denials and documentation Identify quality measures under the IPPS.
  12. Describe case-mix index and its relevance to CDI programs.
  13. Educate providers and other members of the health care team about the importance of the documentation improvement program.
  14. Discuss consultation practices with compliance and HIM department regarding legal issues surrounding CDI efforts.
  15. Develop education for the appropriate staff on the clinical documentation improvement program including accurate & ethical documentation practices.
  16. Describe CDI ethics.
  17. Identify differing methodologies for evaluating documentation program standards (e.g., CC/MCC capture, severity of illness, risk of mortality).
  18. Develop an ability to track and trend data to measure performance over time.
  19. Explain how physician documentation affects publicly accessible Web sites and data (e.g., Leapfrog, HealthGrades).

Program of Study

While the College makes every effort to avoid schedule changes, the College may cancel courses or alter course schedules without prior notification.

Courses

CDI 2010Record Review and Clinical Coding Practice

3
CDI 2020Metrics, Education and Leadership

3

Students are awarded the certificate after meeting the criteria below: 

  • Successful completion of the certificate program as prescribed by the College
  • A cumulative grade point average of 2.0 or higher
  • A minimum grade of D (63-66) in each course within the CDI program
  • Completion of all CDI program requirements within one year of enrollment at the College