The learner will: Explain the purpose and goals of Clinical Documentation Improvement and its impact on coding and reimbursement accuracy. Identify essential documentation components required to support coding specificity and compliance. Evaluate clinical documentation samples to determine adherence to CDI and regulatory standards. Apply structured documentation templates to enhance completeness and billing accuracy. Analyze documentation errors that contribute to claim denials and data discrepancies. Create a comprehensive CDI improvement plan addressing process gaps and departmental needs.

Before beginning this unit, learners should have: Basic knowledge of medical terminology, anatomy, and pathophysiology. Familiarity with ICD-10-CM, CPT, and HCPCS coding systems. Completion of Unit 3.1: Charge Capture Essentials or equivalent practical experience in healthcare billing or documentation.

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This unit is ideal for professionals and students seeking to strengthen their expertise in documentation accuracy, coding integrity, and data quality improvement. It benefits: Clinical Documentation Specialists (CDS) – aiming to refine CDI practices and physician query processes. Medical Coders and Auditors – focused on ensuring that coded data accurately reflects clinical reality. Healthcare Quality and Compliance Officers – ensuring documentation supports regulatory and audit readiness. Nurses, Physicians, and Allied Health Professionals – interested in understanding how documentation affects coding, billing, and quality reporting. Students or Career Changers – pursuing foundational knowledge in CDI to enter healthcare documentation and data integrity roles.