October 25-28, 2020, 11:00 AM – 4:00 PM, GULF STANDARD TIME (UTC + 04:00)

Training Objectives

  • Understand and appreciate the myriad of uses of the medical record beyond reimbursement, all directly related to the quality of documentation and communication of patient care
  • Recognize the current limitations of present-day CDI processes that detract from achievement of clinical documentation excellence
  • Gain the knowledge and practical understanding and application of best practice standards and principles of physician documentation
  • Become proficient in and be able to identify and recognize common documentation insufficiencies and pitfalls that detract from accurately conveying the patient story and need for hospital level of care
  • Be able to competently review a medical record and identify real documentation integrity opportunities in 5 minutes or less
  • Become a cultural change agent through effective listening and communication
  • Transform denials management to denials avoidance through affecting process improvement
  • Engaging physicians and inspiring them to better tell reliably the patient story
  • Best way to measure program performance through valid and reliable “Non-Tasked” Based outcomes
  • Learn to see the record the way reviewers do and avoid self-inflicted denials
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Instructor of this course

Glenn Krauss

CDI Revenue Cycle Professional-CDI Evangelist
Founder of Core-CDI
Co-Founder Top Gun Audit School


More Detail

The medical record serves as a physician communication tool first and foremost versus a reimbursement tool as is the norm today. Fundamental to healthcare, the cement of healthcare delivery and patient care, is the quality and completeness of physician documentation reflective of the care provided. Clinical documentation improvement programs, now known as clinical documentation integrity programs, purport to enhance the accuracy and quality of physician documentation through the query process.

Present day CDI programs by design and intent only scratch the surface in addressing clinical documentation integrity opportunities by primarily focusing upon CC/MCC capture. The CDI profession can effectively drive real improvement in physician documentation, engaging physicians as willing participants in learning about and becoming more proficient in best practice standards and principles of documentation that effectively communicate the fully informed quality focused patient centered coordinated care.

Participants who complete the course will get an opportunity to:

  • FULLY understand how the Medical Record IS practicing medicine, and inseparable from it.
  • Understand the Basic Standards of Documentation recognized worldwide.
  • Believe that Copy & Paste is only helpful and viable with EDITS.
  • Understand the Role of Medical Necessity in all communication and documentation.
  • Learn to enable ALL other areas of Clinical Care & Revenue Cycle through active support of complete and accurate documentation of a patient encounter.
  • Learn to conduct truly complete Chart Reviews quickly, to support all involved.
  • Learn how to share what you know with others – everyone on your right and left.
  • Learn multiple strategies/methods to engage Physicians and others, showing yourself to be a resource for support of both patients and staff.
  • Adoption of a new proactive mindset for Denials Avoidance/Prevention, instead of the reactive Denials Management.
  • Adoption of a new outlook on KPIs and measuring success: Performance/Results vs. Tasks/Checklists.  (i.e., throughput vs. internal measures)

Heads, Managers,  Officers & Co-Coordinators of:

  • Clinical Documentation Improvement
  • Medical Records Department
  • HIM Professionals
  • Revenue Cycles Management Specialists
  • Medical Billing Specialists
  • Coders
  • Physicians and Nurses
  • Professionals engaged in providing guidance related to clinical documentation
  • Online presentations & lectures
  • Group wise interactive discussions, individual & group assignments
  • Group discussions focused on real-world case studies
  • Online quizzes, exercises & use cases
  • Certificate of achievement
  • Course material

Course Fee $950/Participant

Book & pay on or before September 16, 2020 & get
10% Discount, USD 855/participant

2 + 1 Exclusive offer:
3 participants for $ 1,900



Day 1 - Sunday 25 October, 2020
Opening Session (10:40 To 11:00)

Opening Remarks  & Introduction

Session One (11:00 To 13:15)

The Medical Record – Myriad of Purposes and Uses

  • Communication of Patient Care
  • Medicolegal
  • Reimbursement
  • Continuity of Care
  • Quality and safety
  • Outcome and research studies

Foundations of Medical Record

  • H & P
  • Progress Notes
  • Consultant Notes
  • Discharge Summaries

Developing and defining standards of documentation

  • Required elements of clinical documentation to effectively communicate patient care
  • Key elements versus contributing elements
  • Sufficient versus insufficient documentation
  • Copy & Paste, Carry Forwards- what is acceptable and appropriate
  • Developing a meaningful copy & paste policy that is enforceable and recognized by medical staff

Creation and role of templates

  • Acceptable vs Nonacceptable
  • Management of templates
  • Integrating templates into the EHR-best practices and standards
  • Development of and use of valid reliable quality scoring tool for baseline assessment and monitoring of clinical documentation over tim
Session Two (13:45 To 16:00)

Medical Necessity

  • Defining medical necessity
  • Role of CDI in establishment medical necessity
  • Translating documentation into medical necessity
  • Capturing clinical judgment and medical decision making

The Enablement Proposition of Better Coding

  • Clinical coding vs Gold Sheet Coding

Role of coder in the revenue cycle

  • Task vs. Role
  • Establishment of medical necessity vs. bill hold throughput
  • Synergistic effect of strong coding/CDI partnership
  • DRG Reconciliation- Putting in Proper Perspective
  • Issue of queries, foe or opponent
  • Physician advisor - playing an integral role in support of coding

End of Day Group Interactive Discussion

Day 2 - Monday 26 October, 2020
Session One (11:00 To 13:15)

Conducting chart reviews

  • Structural and foundation processes

What to look for

  • Identifying under documentation, over documentation
  • Missed opportunities for additional diagnoses, inclusion of more specific diagnoses
  • Incomplete & insufficient documentation detracting from establishment of medical necessity, admission and continued stay
  • Interacting with Case Management and Utilization Review
  • Designing a triad approach to documentation improvement- synergies of CDI/Case Management/UR

Retrospective queries vs. real time communication with physicians

  • Compliant queries- reaching a happy medium
  • Winning the war and picking your battles
  • Creation of a “Teaching Moment” culture of learning vs. repetitive queries

Knowledge sharing of best practice principles and standards of documentation

  • Designing training material and approaches for different educational training open door forums
  • Creation of widely varied toolbox of reference material and resources
  • Creation of a formalized tailored curriculum for physician training and knowledge sharing on best practice principles and standards of documentation

Group Practical Exercise: Performing & Reporting Chart Reviews


Session Two (13:45 To 16:00)

Engagement of physicians

  • Creation of vision that inspires physicians
  • Facilitators in Communication Patient Care versus Diagnosis Capture
  • Time saving techniques of documentation to share
  • Strategies to engage physicians-understanding and identifying main points of documentation

Maintaining relevance and commitment to up-to-date documentation principles, standards and CMS provisions/regulations governing documentation requirements.

  • Relevant resources
  • Let the internet work for you versus vice versa
  • Sharing of updates to documentation requirements and CMS MAC reviews and notices with physicians
  • Engaging physicians as willing participants in learning about, becoming more proficient in and integrating best practice principles and standards of documentation into their daily practice of medicine

Role-Play Exercise: Physician Engagement
End of Day Group Interactive Discussion

Day 3 - Tuesday 27 October, 2020
Session One (11:00 To 13:15)

Transforming Denials Management to Denials Avoidance

  • Understanding the denials game
  • Why are payers winning
  • Factors that contribute to denials
  • Working with denials and appeals-operational strategies driving process improvement Importance and creation of feedback loop
  • Feedback to physicians- positive behavior modification
  • Tracking and trending-physician report cards
  • Zero sum game- 80 20 rule

Keeping CDI Program Cutting Edge and Fresh

  • Looking for and adopting ways of keeping program relevant and up-to-date
  • Soliciting continual input and desires from physicians to keep program fresh and up-to-date
  • Techniques and approaches to deliver new distinct messages of documentation improvement
  • Role of software in CDI, efficiency tools vs, actual improvement tools physicians can use


Session Two (13:45 To 16:00)

Key Performance Indicators

  • What is contributing to the increasing volume of medical necessity denials?
  • Why are the majority of medical necessity denials avoidable, considered self-inflicted?
  • How can CDI play a major role in driving down and alleviating a sizeable number of these costly medical necessity denials?
  • How can CDI provide feedback to physicians on these medical necessity denials from a documentation CDI perspective, developing an effective sensible process of continual feedback loop to physicians in the name of denials mitigation?

What Can CDI Learn From Those Pesky Medical Necessity Denials?

  • Present day KPIs vs. More reliable valid indicators
  • Measuring documentation improvement processes vs. reimbursement outcomes
  • Role of additional valid and reliable indicators
  • Which KPIs to consider that validly and reliably measure true performance of the CDI program.

Group Practical Exercise: Performing & Reporting Med Necy Reviews
End of Day Group Interactive Discussion

Day 4 - Wednesday 28 October, 2020
Session One (11:00 To 13:15)

How to think like a reviewer?

  • What are reviewers looking for in the chart from a documentation perspective?
  • What are the common documentation deficiencies and insufficiencies that contribute to unnecessary medical necessity and clinical validation denials, DRG downgrades and level of care downgrades?
  • How does thinking like a reviewer facilitate a holistic approach and mindset to CDI chart review and achievement of a complete and accurate documentation of patient care, well describing the patient story and establishment of medical necessity?
  • How to address true documentation insufficiencies and oversights with the physician in a meaningful positive manner?

Changing Culture

  • What are the resistance factors in CDI that pose a roadblock to changing existing culture in CDI that detract from attaining optimal performance?
  • What are the fundamentals required to successfully change existing culture in CDI and the revenue cycle?
  • How to develop and implement a roadmap for changing culture?
  • How to change expectations for physicians and CDI staff, necessary to change the culture of documentation


Session Two (13:45 To 16:00)

Review of Days 1 & 2 – What did you learn?

  • The Medical Record
  • Documentation Standards
  • The Deal-Breaker: Medical Necessity
  • Other Staff & Departmental Roles

Q&A - Interactive Discussion
Review of Days 3 & 4 – What did you learn?

  • Engaging Physicians
  • Staying Up-to-Date & Relevant
  • Moving from Reactive to Proactive
  • Lessons Reviewing Med Necy Denials
  • Key Performance Indicators

Q&A - Interactive Discussion
Feedback, Closing Remarks/Certificate Distribution

Course Program
Time Topic
Day 1
10:40 to 11:00Registration & Introduction
Day 1-4
11:00 to 13:15Session One
13:15 to 13:45Break
13:45 to 16:00Session Two