Bring Balance to your Clinical Documentation


“Throughout the presentation we’ll discuss what the payors’ auditors are looking for to identify outliers and deny claims, and will conclude with a plan on how to incorporate a self-audit program for your practice.”

The first rule in medical coding is: If it wasn’t documented, it wasn’t done.

In this presentation we will look at best practices and requisite language for documenting specific services including surgical procedures, infusions, and telehealth visits, as well as the verbiage necessary for incident-to, shared-service, and teaching physician encounters. 

We’ll discuss the importance of identifying all of the diagnoses being treated during a patient encounter and the importance of including this information on your claim. We’ll also take a deep dive into the documentation requirements for outpatient evaluation and management services this year, with an emphasis on the adjusted medical-decision-making components.

Identify ways to improve your medical records documentation to better support the services you’re providing, reduce denials, and “audit proof” your claims with this presentation.

“This program has been approved for a maximum of 1.00 continuing education unit(s) per person for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.”


Siji Susan Joy


Over 17 years of experience in HIM domain , leading HIM coding/audit services and analytics solution projects for providers & payers of US & UAE industries . Applies the Clinical Coding domain expertise to identify revenue opportunities for payers & providers using HIM technology, analytics, and research initiatives to improve the quality of care.

Contributes for Payment integrity audit solution/product development strategies for Healthcare Claims Fraud and Abuse detection, Population Health Analytics and Claims Audit Solutions to prevent resubmissions & revenue leakages, Clinical Data Mapping projects and Quality Measure Development.

Extensive experience in HIM coding validation and post-payment audits.

Educator for Clinical coding Academies to promote continuing education activities to meet the industry & project standards

CDI Recorded webinar
64 min
10 questions

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Bring Balance to your Clinical Documentation