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Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
A RHIA certification is a preferred qualification for positions including health information management director, clinical documentation improvement professional (CDIP), and registered health information administrator.
Healthcare quality and safety require that the right information be available at the right time to support patient care and health system management decisions. Gaining consensus on essential data content and documentation standards is a necessary prerequisite for high-quality data in the interconnected healthcare system of the future.
A clinical coder therefore requires a good knowledge of medical terminology, anatomy and physiology, a basic knowledge of clinical procedures and diseases and injuries and other conditions, medical illustrations, clinical documentation (such as medical or surgical reports and patient charts), legal and ethical aspects of health information ...
AAPC provides training, certification, [9] and other services to individuals and organizations across medical coding, medical billing, auditing, compliance, and practice management. These services include networking events such as medical coding seminars and conferences.
Traditionally focused mainly on hospitals and paper medical records, the field presently covers all health information technology systems, including electronic health records, clinical decision support systems, and so on, for all segments of health care. As of 2013, the association has more than 71,000 members in four membership classifications.
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