Medical Coding vs. Clinical Documentation

Jun 20, 2025

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The PowerPoint presentation delves into the differences between medical coding and clinical documentation, highlighting their individual roles and how they intersect within the healthcare ecosystem. It explains that clinical documentation is the detailed record of patient interactions maintained by doctors, nurses, and other care providers, while medical coding translates these records into universal codes used for reimbursement, compliance, and analytics. The slides include visual aids, definitions, examples, and a comparative analysis to enhance clarity and engagement. This presentation serv

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Medical Coding vs. Clinical Documentation

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medical coding services | medical coding company

Error free claims and timely claims submission are vital to get paid faster. We offer medical coding services, that can do just that! We are hipaa complaint, affordable and offer across the board medical coding and billing services. Call us @1-888-571-9069" visit us :http://www.medicalbillingstar.com/medical-coding.html"

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CPT Coding &Clinical Documentation Training Module

CPT Coding &Clinical Documentation Training Module. Department of Billing & Collections. Objectives. Review Centers for Medicare and Medicaid Service (CMS) documentation guidelines for outpatient-inpatient evaluation and management services.

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CLINICAL DOCUMENTATION TRAINING

Press ENTER for next slide.. 2. Training Information. This training is one of four sections available sections.Following each section there will be questions relating to the material covered in that section.To obtain CEU's, either complete the accompanying test; or, write down your name, social se

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Medical coding

Applications of Health Informatics. Medical coding. John Graunt began the statistical study of disease in the early 17 th century 1837 William Farr wanted adoption of a uniform classification of causes of death

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Coding and Documentation Improvement

Coding and Documentation Improvement. Theresa Cuoco, MD, FACP Ashley Duckett, MD Medical University of South Carolina 2012. Objectives. Understand purpose of Utilization Review Improve History and Physical and Progress Note documentation

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Clinical coding:

Clinical coding:. s hould we be going back to the basics?. “Perfection is not attainable, but if we chase perfection we can catch excellence” Vince Lombardi (American Football Coach). National Centre for Classification in Health, The University of Sydney. Vera Dimitropoulos.

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Clinical Documentation

Clinical Documentation. 2006 Annual Texas Institute on Substance Abuse and Mental Health Rhonda G. Patrick, LCSW . Clinical Documentation. ASSESSMENT. What is the assessment?.

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Clinical Documentation Improvement

Clinical Documentation Improvement . Langley Provider Group Colleen Garry RN, BS Mary Beth Genovese RN, BS, CCS, CCDS. JAMA: April 26, 2006 p. 1918.

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Diabetes Coding and Documentation

Diabetes Coding and Documentation. Provider Education. Overview. Diabetes is a chronic illness that requires continuing medical care and ongoing patient self management education and support to prevent acute complications and to reduce the risk of long-term complications.

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Clinical Documentation

Clinical Documentation. Pharmacy Department Dale Tucker, RPh, BCPS Harper University Hospital Hutzel Women’s Hospital Karmanos Cancer Hospital Rehabilitation Institute of Michigan Last Updated July 2005 with evaluation by Julie Berman (DRH), Albert Bajjoka (HVSH),

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CLINICAL SUPPORT VS DOCUMENTATION

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Clinical Documentation and Coding: The Way Forward

Clinical Documentation and Coding: The Way Forward. CAPT Rebecca McCormick-Boyle Assistant Deputy Chief, Current Operations, BUMED M3B. The Process: From Clinical Documentation to Decision Making. INPUTS. Clinical Documentation. Coding. OUTPUTS. Resourcing.

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MEDICAL CODING

MEDICAL CODING. INTRODUCTION FOR A CAREER Presented by Lyn Olsen,Ph.D ., MPA, RHIT, CCS, CPC-H, CCS-P, CPC www.tseas.wordpress.com. WHAT IS MEDICAL CODING AND BILLING?. MEDICAL CODING & BILLING ARE THE CORE OF ADMINISTRATIVE MEANS BY WHICH HEALTHCARE PROVIDERS ARE PAID

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Clinical Documentation

Clinical Documentation. Amish A Dangodara, MD, FACP Professor of Medicine Hospitalist Program University of California, Irvine School of Medicine 07.11.14. Need 2 Volunteers: R1 & R3. Clinical Documentation. Chief Complaint HPI: 4+ elements of chief complaint Past Hx: 3/3 PMHx

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Medical Documentation

Medical Documentation. Avni Bhalakia, M.D. St. Barnabas Hospital July 29, 2009. Objectives. Purpose of the Medical Record Importance of Documentation HOW TO Document WHAT TO Document Medical Student Documentation Inpatient Documents Medication Reconciliation Summary.

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Clinical Documentation Improvement. CDI. Why?. Your documentation reflects the patient in the bed, the necessity of clinical diagnostics, the need for continued length of stay (LOS) and the quality of care provided.

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Reimbursement, Coding, & Documentation

Reimbursement, Coding, & Documentation. Antonio E. Puente, Ph.D. University of North Carolina at Wilmington Annual Behavioral, Clinical, Neuropsychological, & Substance Abuse Conference October 19, 2000 Los Angeles, California. History of Reimbursement. Cost Plus Reimbursement

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Clinical Documentation Improvement

Clinical Documentation Improvement. (CDI). Objectives. !. What is CDI and why is it associated with ICD-10? 2. How to share information with physicians. 3.Longer time frame now. Delayed 10/1/2015 4. Will it be ICD-10 or ICD-11. Diabetes Mellitus 250.00 – 250.93.

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The Relationship between Health Record Documentation and Clinical Coding

The Relationship between Health Record Documentation and Clinical Coding. Lorraine Nicholson President of IFHRO (International Federation of Health Records Organisations) & Independent Health Records Consultant Co-Author: Sue Walker

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ChartWise Medical Systems - clinical documentation

We designs innovative hosted software solutions for hospitals which improves clinical documentation quality. It mitigate risk, maximize reimbursement and gain insight into their documentation improvement efforts. Visit us to know more...http://www.chartwisemed.com/

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Diagnosis Coding and Documentation

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Medical Coding vs. Clinical Documentation

Medical Coding vs. Clinical Documentation

Presentation Transcript

medical coding services | medical coding company

CPT Coding &amp;Clinical Documentation Training Module

CLINICAL DOCUMENTATION TRAINING

Medical coding

Coding and Documentation Improvement

Clinical coding:

Clinical Documentation

Clinical Documentation Improvement

Diabetes Coding and Documentation

Clinical Documentation

CLINICAL SUPPORT VS DOCUMENTATION

Clinical Documentation and Coding: The Way Forward

MEDICAL CODING

Clinical Documentation

Medical Documentation

Clinical Documentation Improvement

Reimbursement, Coding, &amp; Documentation

Clinical Documentation Improvement

The Relationship between Health Record Documentation and Clinical Coding

ChartWise Medical Systems - clinical documentation

Diagnosis Coding and Documentation

Clinical Coding

CPT Coding &Clinical Documentation Training Module

Reimbursement, Coding, & Documentation