HIM 475: Compliance and Medical Necessity

Course Description

In this course, students will focus on CDI ethical principles, compliant queries, and clinical validation. Topics will include bidirectional clinical indicators, case studies by diagnosis, ethics in CDI, the criteria for quality documentation and communication of patient care. Discussion on how CDI relates to insurance coverage will be included. There will also be a focus on medical necessity and case studies on denials for medical necessity. Lastly, students will study the expanding role of CDI leadership and how it directly relates to the financial health of the healthcare organization.

(3 credits)

Prerequisites

  • BIO 212: Anatomy and Physiology
  • BIO 215: Pathophysiology
  • HCA 105: Medical Terminology
  • HIM 205: Reimbursement Methodologies
  • HIM 210: Clinical Classification Systems 1
  • HIM 211: Clinical Classification Systems 2
  • HIM 371: Revenue Cycle and CDI*
  • HIM 373: CDI Operational Process*

* May be taken concurrently.

Student Learning Outcomes (SLOs)

Upon successful completion of the course, the student will be able to:

  1. Identify ethical principles related to CDI.
  2. Construct a non-leading compliant query.
  3. Establish the relationship between CDI and insurance coverage.
  4. Analyze the expanding role of CDI leadership and the financial impact of an organization.
  5. Critique documentation for quality and determine if it effectively communicates patient care.
  6. Evaluate provider documentation to determine clinical validation.
  7. Assess documentation for its impact on medical necessity.
  8. Evaluate insurance denials for both medical necessity and clinical validation.
  9. Evaluate documentation that may lead to payer denials.
  10. Articulate effective communication through discussion and query construction.

Course Activities and Grading

AssignmentsWeight

Discussions (Weeks 1-8)

24%

Assignments (Weeks 1-8)

52%

Quizzes (Weeks 1-7)

14%

Final Exam (Week 8)

10%

Total

100%

Required Textbooks

Available through Charter Oak State College's Book Bundle

  • Hess, P.C. Clinical Documentation Improvement: Principles and Practice. AHIMA, 2015. ISBN-13:  978-1-58426-502-3

  • Pinson & Tang. 2024 CDI Pocket Guide. 17th ed. Pinson & Tang, 2023. ISBN-13: 978-1-7334594-7-1

Additional Resources

Course Schedule

Week

SLOs

Readings and Exercises

Assignments

1

1

Topics:  Ethical Principles and Compliance

  • Reading:
    • Hess, Chapter 12, pp. 207-224
    • American Health Information Management Association (2021). Ethical standards for Clinical Documentation Improvement (CDI) professionals
    • Association of Clinical Documentation Improvement Specialists (2021). Association for clinical documentation specialists code of ethics
    • Association of Clinical Documentation Improvement Specialists (2021). Association for clinical documentation specialists code of ethics: Poster
  • Review Getting Started information
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 1 Assignment
  • Complete Week 1 Quiz

2

5,6

Topic:  Clinical Validation

  • Reading:
    • Read Association of Clinical Doumentation Integrity Specialists. (2021, March 16). CDI Tip: The role of clinical validation in CDI
    • (2019, January). Clinical validation: The next level of CDI (January 2019 update) [Practice brief update].
    • Suttles, A., Brisson, A., & Stanfill, M. H. (2020). Preventing denials through clinical validation. Journal of AHIMA.
    • Pinson & Tang. (2021). Clinical Validation
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 2 Assignment
  • Complete Week 2 Quiz

3

1,2,10

Topic: Effective Communication

  • Reading:
    • Education Executive. (2017, June 28). The seven cs of communication. Edexec | Supporting Business and Financial Excellence in Schools and Academies.
    • American Health Information Management Association. (2019). AHIMA inpatient query toolkit.
    • AHIMA. (2019). Guidelines for achieving a compliant query practice FAQs. Journal of AHIMA, 90 (10), 34–35.
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 3 Assignment
  • Complete Week 3 Quiz

4

5,7,9

Topics: CDI and Quality Documentation

  • Readings:
    • Combs, T. (2020, April 1). The importance of high-quality clinical documentation across the healthcare continuum. Journal of AHIMA.
    • BCE Healthcare Advisors. (n.d.). The Top Seven Reasons Clinical Documentation Is More Important Now Than Ever.
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 4 Assignment
  • Complete Week 4 Quiz

5

5,7

Topics: CDI and Communication of Care and the Impact on Medical Necessity

  • Reading:
    • Buckholtz, R. (2018, January 15). CDI and Medical Necessity: Closing the Gap
      Could Prevent Denials.
    • Remer, E. E. (2017, April 24). Excellent Documentation is Necessary to Meet Medical Necessity. ICD10monitor.
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 5 Assignment
  • Complete Week 5 Quiz

6

3,8,9

Topics: CDI and Relationship with Insurance Coverage

  • Readings:
    • Bowman, S., Campbell, A., Crow, L., Foley, M., Land, D., Lockwood, F., McNicholas, F., Poleon, C., Rugg, D., & Thornton, L. (2019). Best Practices for Denials Prevention and Management. Journal of AHIMA, 90(3), 36–39.
    • Blevins, D., Combs, T., Ericson, C., Ison, C. M., Jones, P., Kozlowski, K., Lovano, I., McNicholas, F., & Peyton, T. (2018). CDI and Coding Collaboration in Denials Management Toolkit. American Health Information Management Association.
      •  
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 6 Assignment
  • Complete Week 6 Quiz

7

4

Topics: CDI and Organizational Financial Health

  • Readings:
    • Ericson, C. (2019, August). A Successful CDI Monitoring Process Can Help Hospitals Avoid Audit Surprises. CodeWrite.
    • Revcycle Intelligence. (2017, October 6). Maximizing Revenue Through Clinical Documentation Improvement.
    • Riel, C. (2021). Show me the money: Proving CDI’s financial ROI. CDI Journal, 6–7.
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 7 Assignment
  • Complete Week 7 Quiz
 8 4,5

Topic: Expanding Roles of CDI Leadership

  • Reading:
    • Association of clinical documentation integrity specialists. (2020). ACDIS Code of Ethics: Poster.
    • Bundenthal, S., Carr, K., Combs, T., Ericson, C., Liebner, C., & Yuen, A. (2021). AHIMA Clinical Documentation Integrity (CDI) Toolkit Beginners’ Guide.
    • ACDIS. (2017, May 18). Developing effective CDI leadership: A matter of effort and attitude.
    • Riel, C. (2020). One rung at a time: CDI career ladders. CDI Journal, September/October, 32–35
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 8 Assignment
  • Complete Final Exam
  • Complete Course Evaluation

COSC Accessibility Statement

Charter Oak State College encourages students with disabilities, including non-visible disabilities such as chronic diseases, learning disabilities, head injury, attention deficit/hyperactive disorder, or psychiatric disabilities, to discuss appropriate accommodations with the Office of Accessibility Services at OAS@charteroak.edu.

COSC Policies, Course Policies, Academic Support Services and Resources

Students are responsible for knowing all Charter Oak State College (COSC) institutional policies, course-specific policies, procedures, and available academic support services and resources. Please see COSC Policies for COSC institutional policies, and see also specific policies related to this course. See COSC Resources for information regarding available academic support services and resources.