ICD10MD membership includes access to all modules until decommission and ability to claim up to 8.0 hours CME until January 12, 2026.
This module is entitled, Clinical Documentation for Neurosurgeons
Presentation run time is 45 minutes.
After participating in this activity participants will be able to:
- Understand why we document
- Recognize the relationship between documentation, quality metrics, and reimbursement
- Improve their quality metrics and decrease inappropriate patient safety indicator assignment
- Incorporate more and best risk-adjusting diagnoses in their documentation
- Respond to queries in a thoughtful, appropriate, and timely fashion
Category: Clinical Documentation for Healthcare Providers
(Front matter:)
Clinical Documentation for Healthcare Providers
Clinical Documentation for Neurosurgeons
Release Date: January 13, 2023
Expiration Date: January 12, 2026
Faculty:
Erica E. Remer, MD, CCDS
President and Founder
Erica Remer, MD, Inc.
Target Audience
This continuing medical education activity is intended for physicians, physician assistants, nurse practitioners, residents, and medical students. It will benefit any healthcare provider who documents in the medicolegal record and wants to optimize their communication, quality metrics, and reimbursement. It may also be useful for clinical documentation integrity professionals to help guide healthcare providers to improve their documentation
Media
Recorded slides and audio presentation.
Learning Objectives
After participating in this activity participants will be able to:
- Understand why we document
- Recognize the relationship between documentation, quality metrics, and reimbursement
- Improve their quality metrics and decrease inappropriate patient safety indicator assignment
- Incorporate more and best risk-adjusting diagnoses in their documentation
- Respond to queries in a thoughtful, appropriate, and timely fashion
Acknowledgement of Financial Commercial Support
No financial commercial support was received for this educational activity.
Acknowledgement of In-Kind Commercial Support
No in-kind commercial support was received for this educational activity.
Satisfactory Completion
Learners must listen to each self-directed audio recording while following along with the visual slides and complete an evaluation form to receive a certificate of completion. Your chosen sessions must be viewed in their entirety. Partial credit of individual sessions is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/certification requirement.
Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by Amedco LLC and Erica Remer MD, Inc.. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physicians (ACCME) Credit Designation
Amedco LLC designates this enduring material (entire package) for a maximum of 8.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Objectives – After Attending This Program You Should Be Able To
- Understand the role of clinical documentation in the practice of medicine
- Modify clinical documentation to provide and demonstrate improved quality of care and to allow for optimized reimbursement
- Use more specific language for important diagnoses to improve coding of encounter
Disclosure of Conflict of Interest
The following table of disclosure information is provided to learners and contains the relevant financial relationships that each individual in a position to control the content disclosed to Amedco. All of these relationships were treated as a conflict of interest, and have been resolved. (C7 SCS 6.1-‐6.2, 6.5)
All individuals in a position to control the content of CE are listed below.
|
First Name |
Last Name |
Commercial Interest: Relationship |
|
Peter |
Babula |
NA |
|
Ryan |
Dixon |
NA |
|
Erica |
Remer |
NA |
How to Get Your Certificate
- This 11-module course is approved for up to 8.0 AMA PRA Category 1 Credits™.
- Take all modules for which you plan to claim CME credit and note the length for which the individual modules are approved for CME.
- After each module, you will be given a choice to take another module now, later, or to indicate that you have completed all modules that you are planning on taking.
- When you are done with all modules for which you plan to claim CME, you will be sent to the site where you will fill out an evaluation and claim your CME certificate. Tally the CME credit for all the modules you took to determine the amount to claim.
- You are welcome to watch any and all modules until decommission, but once you have claimed your CME, you cannot claim additional credits.
Questions? Email [email protected]
Contact Information
If you have questions regarding this enduring material activity, please contact Erica Remer [email protected].
Estimated Time to Complete this Educational Activity
Including review of any resource material, this activity is expected to take 0.75 hour to complete.
Fee
This module is part of a package of documentation modules priced at $349 for the set.
Resources
Evaluation and Management Services, Medicare Learning Network, CMS, August 2017, January 2022. (check cms.gov for eventual pending updates).
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
- https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
Guidelines for Teaching Physicians, Interns, and Residents, MLN booklet, CMS, 2017.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-Physicians-Fact-Sheet-ICN006437.pdf
Patient Safety Indicators, Agency for Healthcare Research and Quality
https://qualityindicators.ahrq.gov/measures/psi_resources
LaCharite T, CDI for Surgeons: What You and They Need to Know, presentation from ACDIS Annual Conference, May 2018.
https://acdis.org/system/files/resources/ACDIS_day1-3_track1-1_pres_0518-La%20Charit%C3%A9_f1.pdf
Zupko K, Op Note Documentation Tips Every Surgeon Can Use, KZA Blog, May 1, 2019.
https://www.karenzupko.com/op-note-documentation-tips-every-surgeon-can-use/
Gadani R, Documentation in Surgery, SlideShare presentation, July 2015.
https://www.slideshare.net/ravi_gadani/documentation-in-surgery
Statement on Documentation and Reporting of Accidental Punctures and Lacerations During Surgery, American College of Surgeons, October 1, 2016.
https://www.facs.org/about-acs/statements/90-accidental-punctures
Mohammad LM, Kimmell K, et. al., Enhanced Documentation and Accurate Coding with the Introduction of a Standardized Neurosurgery History and Physical Template, 2019 AANS Annual Scientific Meeting, San Diego CA, April 2019.
https://thejns.org/view/journals/j-neurosurg/131/1/article-p2.xml
Spurgeon A, Hiser B, et. al., Does Improving Medical Record Documentation Better Reflect Severity of Illness in Neurosurgical Patients?, Clinical Neurosurgery, Volume 58, 2011.
Rosenbaum BP, Lorenz RR, et. al., Improving and Measuring Inpatient Documentation of Medical Care with the MS-DRG System: Education, Monitoring, and Normalized Case Mix Index, Perspect Health Inf Manag, 2014 Summer: 11(Summer); 1c, 2014.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142511/
