Training and education

Focus on providing education and training to nurses, clinical documentation specialists, coders, and doctors. Practical training and education are essential to enhance the knowledge of healthcare professionals, ensuring documentation requirements and updating with coding guidelines and industry best practices. The growing learning culture through training and education will contribute to sustaining the Clinical Documentation Improvement (CDI’s) success.

Collaboration

Clinical Documentation Improvement (CDI) can only be possible with collaboration among healthcare professionals. CDI helps improve communication and documentation requirements and fosters an understanding of clinical conditions.

Documentation integrity and feedback

The fundamental and crucial element of medical billing and coding is integrity. It requires that coders are candid, honest, and forthright regarding the accurate clinical documentation of the patients. It is about coding and billing ethics that they should restrict themselves from advantage or personal gains when using confidential information. However, laws about the applicability and difference in opinion do exist. Professional coders and billers must avoid any intentional opportunity to manipulate or deceive the clinical documentation information. At the same time, involve all parties, urge them to provide feedback, and welcome them to collect constructive suggestions. Read More...