Description
Clinical Documentation for Healthcare Providers – Clinical Documentation: How CDI Can Help
Release Date: December 1, 2019
Expiration Date: November 30, 2022
Faculty:
Erica E. Remer, MD, CCDS
President and Founder
Erica Remer, MD, Inc.
Dr. Remer reports no financial relationship with a commercial interest relevant to this activity.
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.
Media
Recorded slides and audio presentation. Posttest will reinforce information presented.
Learning Objectives
After participating in this activity participants will be able to:
- Recognize the clinical documentation integrity specialist’s role in improving documentation
- Incorporate more, risk-adjusting diagnoses in their documentation
- Respond to queries in a thoughtful, appropriate fashion
- Document in a codable format to demonstrate quality of care
Accreditation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Case Western Reserve University School of Medicine and Erica Remer, MD, Inc. Case Western Reserve University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Case Western Reserve University School of Medicine designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Planning Committee
Joan Zoltanski, MD, MBA, Activity Director
Chief Experience Officer
University Hospitals of Cleveland
Assistant Professor, Pediatrics
Case Western Reserve University School of Medicine
Dr. Zoltanski reports no financial relationship with a commercial interest relevant to this activity.
Erica E. Remer, MD, CCDS Co-Activity Director
President and Founder
Erica Remer, MD, Inc.
Dr. Remer reports no financial relationship with a commercial interest relevant to this activity.
Disclosure Statement
The policy of Case Western Reserve University School of Medicine CME Program (CWRU CME) requires that the Activity Director, planning committee members and all activity faculty (that is, anyone in a position to control the content of the educational activity) disclose to the activity participants all relevant financial relationships with commercial interests. Where disclosures have been made, conflicts of interest, real or apparent, must be resolved. Disclosure will be made to activity participants prior to the commencement of the activity. CWRU CME also requires that faculty make clinical recommendations based on the best available scientific evidence and that faculty identify any discussion of “off-label” or investigational use of pharmaceutical products or medical devices.
Instructions
To receive a statement of credit for up to 0.75 AMA PRA Category 1 CreditTM you must:
- Review and reflect on the full content of the recorded session.
- Successfully complete the posttest. A score of 100% is required for passage.
- Complete the evaluation.
- Claim your credit.
Your credits will be recorded by the CWRU CME Program and made a part of your cumulative transcript.
Estimated Time to Complete this Educational Activity
Including review of any resource material and completion of the post-test, this activity is expected to take 0.75 hour to complete.
Fee
The cost of this program is $189.
To contact the CME Provider: Email CWRU CME at [email protected]
Resources
Guidelines for Achieving a Compliant Query Practice – 2019 update, ACDIS/AHIMA joint position paper, February 13, 2019.
NINDS, Encephalopathy Information Page,
https://www.ninds.nih.gov/Disorders/All-Disorders/Encephalopathy-Information-Page
Pinson R, Functional quadriplegia, ACP Hospitalist, Coding Corner, May 2012.
https://acphospitalist.org/archives/2012/05/coding.htm
Remer EE, Is All Airway Protection Acute Respiratory Failure? icd10monitor.com, July 16, 2018. https://www.icd10monitor.com/is-all-airway-protection-acute-respiratory-failure
Thygesen K, Alpert JS, et. al., Fourth Universal Definition of Myocardial Infarction (2018), JACC, August 2018. http://www.onlinejacc.org/content/early/2018/08/22/j.jacc.2018.08.1038
KDIGO Clinical Practice Guideline for Acute Kidney Injury, Kidney International Supplements, Vol 2, Issue 1, March 2012.
https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf
Singer M, Deutschman CS, et. al., The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), JAMA, 2016; 315(8):801-810.
https://jamanetwork.com/journals/jama/fullarticle/2492881
Surviving Sepsis Campaign, see website for publications and presentations:
http://www.survivingsepsis.org/Guidelines/Pages/default.aspx
Malnutrition Solution Center, American Society for Parenteral and Enteral Nutrition, see website for guidelines, videos, and resources:
https://www.nutritioncare.org/guidelines_and_clinical_resources/Malnutrition_Solution_Center/
Jensen GL, Cederholm T, et. al., GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community, JPEN, Vol. 43, Issue 1, Pages 32-40, January 2019. https://onlinelibrary.wiley.com/doi/full/10.1002/jpen.1440