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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 ...
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The program started as a way to provide educational intervention to physicians who were identified by the Board and had received ethical infractions. By 1996, the ProBE Program had been endorsed by 45 licensing boards and sub-specialty boards throughout the United States. In 2007, CPEP acquired The Ethics Group, LLC, and began offering the program.
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
Teaching clinics traditionally are operated by educational facilities and provide free or low-cost services to patients. [15] Nurse education–Some teaching hospitals partner with nursing education institutions to provide in-hospital, practical education for nurses, both graduate and undergraduate. [1]
ICD-10 is the 10th revision of the International Classification of Diseases (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. [1]
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