HIM 491: CDI Case Study Practicum

Course Description

This course is the culmination of the CDI certificate and will focus on real-world practice through case studies and clinical application. Students will apply the principles of query and optimal DRG assignment. This practice will be critical in preparing students for a role in CDI employment and the experience and knowledge needed to work as a CDI specialist.

(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*
• HIM 475: Compliance and Medical Necessity*

* May be taken concurrently.

Program Learning Outcomes (PLOs)

Students who graduate with a major in Health Information Management will be able to:

1. Demonstrate an understanding of the different fields of medical science, information technology, and business management applicable in health information management.
2. Demonstrate a fundamental knowledge of facts, terms, and concepts important to the processing of health information.
3. Apply information acquisition skills to the processing, maintenance, and security of health information.
4. Demonstrate an ability to do the coding and billing important in the processing of health information.
5. Understand database information technology and apply it to modern electronic medical records management.
6. Understand and use quantitative and qualitative research methodologies in health information management.
7. Demonstrate an understanding of the importance of maintaining quality management techniques in health information management.
8. Demonstrate an understanding of the importance of the maintenance of staff development in health information management.
9. Understand and use project management techniques and their application to modern business management.

Student Learning Outcomes (SLOs)

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

1. Evaluate the medical record for complete and accurate documentatio.
2. Utilize concepts learned in HIM 371, HIM 373, HIM 475, and HIM 477 to master documentation while performing a medical record review.
3. Construct effective queries utilizing concepts from the AHIMA Guidelines for Achieving a Compliant Query Brief, Official Guidelines for Coding and Reporting, AHA Coding Clinic, and AHIMA Standards for Clinical Documentation Integrity (CDI) Professionals (2020).
4. Critique provider documentation to determine if it effectively communicates the patient encounter.
5. Plan a medical record review routine.
6. Evaluate the relationship between CDI and the revenue cycle and how it impacts the financial health of the organization including review of principal diagnosis, MCC/CC capture, Health Care Acquired Conditions, and Patient Safety Indicators.
7. Evaluate and critique CDI key performance indicators (KPI) and metrics.
8. Relate on how to access learning resources and tools to prepare for the CDIP exam.
9. Develop provider education as identified.
10. Evaluate and assign the working DRG.
11. Analyze how query capture of principal diagnosis, CC/MCC, and clinical validation impact DRG relative weights, severity of illness, rate of mortality, and potential reimbursement.

Course Activities and Grading

Required Textbooks

Available through Charter Oak State College's Book Bundle

• Easterling, S. Certified Documentation Improvement Practitioner (CDIP) Exam Preparation. 2nd. ed. AHIMA, 2023.
• Hess, P.C. (2015). Clinical documentation improvement: Principles and Practice. 1st. ed. AHIMA, American Health Information Management Association.

Additional Resources

• AHIMA (2015). Clinical Documentation Integrity (CDI) Toolkit Beginners’ Guide. 
• AHIMA (2016). Clinical Documentation Improvement Toolkit (2016 version).
• AHIMA (2019). Inpatient Query Toolkit.
• AHIMA (2018). Outpatient Clinical Documentation Improvement (CDI) Toolkit.
• Devault, K & Stanfill, M. Components of an Effective Inpatient Coding Compliance Program. Journal of AHIMA, no. 7 (Jul-Aug): 50-52

Course Schedule

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.