CDI Online: For the Clinic or Outpatient Medical Office

October 10, 2023

CDI Online: For the Clinic or Outpatient Medical Office

Check out this online course offered by the American Institute of Healthcare Compliance (AIHC) for medical office professionals. This course is designed for experienced health information management (HIM) professionals, office nurses (RNs, LPHs), professional coders, chart auditors, and those working in a health plan Special Investigation Units (SIU). Providers and other individuals tasked with the responsibility of improving documentation standards for medical practices are also encouraged to register.

Appropriate documentation is an important part of your practice compliance program.

Learning Objectives

  • Overview of Clinical Documentation Improvement (CDI)
    • Facing challenges of medical office CDI professional
    • Managing conflict
    • Know the language of medicine
  • Basics of compliant documentation
    • The medical record is a legal document
    • Top #1 high risk practice coding issue
    • Signature requirements, acceptable and unacceptable practices
    • Addendums, corrections and deletions to the medical record
  • Intro to E/M documentation improvement
    • Overview of clinical documentation & progress (clinical) notes
    • Achieving compliant E/M documentation to avoid fraud, abuse & waste
    • There is a changing health care environment – increased poverty
    • Documentation and addressing social determinants of health
    • Reimbursement depends on capturing documentation
    • Measuring SDOH program performance
  • Office/Outpatient visit documentation considerations
    • New patient E&M visits
    • Established patient E&M visits
  • Other E/M services and documentation considerations
    • Emergency department
    • Inpatient/Observation as of 2023
    • Discharge services
    • Consultations
  • E/M and documentation of time
    • Concept of time, documentation, and levels of service for E/M as of 2023
    • Know what counts as “time”
    • Split/shared visits & time
    • Prolonger services and time
    • Discharge management
    • Time & critical care visits
  • E/M and documentation of MDM
    • Medical decision-making (MDM) for evaluation & management as of 2023
    • Using MDM Table to select level of service
    • Terms & definitions related to MDM
  • Operative notes & compliant documentation
    • General principles of operative notes documentation
    • Documentation to support appropriate reimbursement
    • Identifying the surgeon, vs the co-surgeon, assistant surgeon, or surgical team
  • Documentation of medical necessity
    • What is medical necessity?
    • General definition of medical necessity for physicians
    • Documentation and coding that demonstrates medical necessity
    • Centers for Medicare and Medicaid (CMS) sets the standard (typically)
    • Documentation requirements for DME
  • Medications, supplies, and diagnostic tests
    • Do no harm – documenting drugs and biologicals (medications)
    • Supplies
  • HIPAA, confidentiality and you, the clinical documentation professional
    • Health Insurance Portability and Accountability Act (HIPAA), Public Law 104-191
    • Special consideration for highly protected psychotherapy notes
    • Patient information pertaining to behavioral health or substance abuse
    • Your EHR and preventing cyber-attacks

Option to certify is included in course tuition to earn your Certified Medical Documentation Professional CMDP credential.


Non-member tuition – $625

AIHC member price – $375

Course tuition is all-inclusive

  • Access to a qualified online instructor if and when you need help
  • Training materials and access to the online training page
  • Quizzes and downloadable information: accessed through the online training page
  • AIHC membership for one year: available for first-time members only.
  • Mock exam: this mock exam is one exam total that covers all of the certification exam domains
  • One certification exam attempt, provided exam is taken within three months of completing the course

Online Registration