Clinical Documentation Integrity Certificate

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Clinical Documentation Integrity (CDI) Program Overview
Clinical documentation improvement, or clinical documentation integrity, may be defined as a process by which clinical indicators, diagnoses, and procedures documented in the medical record are supported by the appropriate ICD-10-CM and ICD-10-PCS codes. Clinical documentation is at the core of every patient encounter. In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, timely, and legible to accurately reflect the patient's disease burden and scope of services provided.

Successful clinical documentation integrity (CDI) programs facilitate the accurate representation of a patient's clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, disease tracking and trending, and medical research.

The convergence of clinical care, documentation, and coding processes is vital to appropriate reimbursement, accurate quality scores, and informed decision-making to support high-quality patient care. CDI has a direct impact on patient care by providing information to all members of the care team as well as those who may be treating the patient at a later date.

Successful CDIPs should have a deep level of clinical knowledge in analyzing patient health records to provide assurance about the captured data from the physician and the coder to ensure accuracy in providing quality patient care. CDI also includes synergistically enhancing the quality of the hospital and the physician to better deliver their services. Physicians should be given an orientation on the role, strategies and methodologies applied by CDIC and be educated on annual DRG, CC, MCC, and HAC changes. This aids in embracing the communication between the physician and the CDI specialist. Setting strategies universally and investing more effort on the team can aid in improving CDI to become more effective and efficient, resulting in a higher quality of patient care and an exemplary healthcare system.

· Improve the quality and integrity of documentation
· Support patient care and improve clinical outcomes
• Identify documentation opportunities and collaborating with both clinical and coding staff
· Reflect each patient's severity of illness and complexity of care · Facilitate timely claim submission 
• Reduce denials by other organizations, RAC

This program offers unique content you can apply to your professional setting. The instructor will cover both inpatient and outpatient settings, creating an even larger return on investment for participants. You will learn about CDI best practices through real-life examples and assessment activities that draw from lesson-specific clinical and coding topics.

Training and Resources
Whether you are new to CDI, transitioning from a coding or clinical background, or an experienced CDI professional, this program will provide you education and resources to support your lifelong learning and continued advancement in clinical documentation improvement.

Training will be provided by AHIMA Approved Clinical Documentation Improvement Trainer and AHIMA Approved ICD-10-CM/PCS Trainer.  

Overview of CDI program and goals  

· MS-DRGs including CCs and MCCs and their impact on MS-DRG assignment The top 10 MS-DRGs for the organization 
· APR DRGs including Severity of Illness (SOI) and Risk of Mortality (ROM) The top 10 APR DRGs for the organization  
·  Hospital Acquired Conditions and their impact  
·  What documentation is used for code assignment and where to find in the paper and electronic medical record  
·  Review of clinical indicators for specific diagnosis such as respiratory failure and protein-calorie malnutrition        

Required Books:  ICD 10 book (latest edition)  

Instructor: AHIMA Approved CDI Trainer    

Eligibility Requirements for AHIMA'S CDIP EXAM: Candidates must meet one of the following eligibility requirements to sit for the CDIP examination: 

· Hold an associate's degree or higher; or
· Hold a CCS®, CCS-P®, RHIT®, or RHIA® credential

While not required, the following are recommended: 

· Minimum of two (2) years of clinical documentation integrity experience 

· Associate's degree or higher in a health care or allied health care discipline 

· Completion of coursework in the following topics:   Medical terminology  -    Human anatomy and physiology  -    Pathology  -    Pharmacology

Exam information can be found by clicking here: 

Application and Registration:

Please click here to download an application for admission.  The completed application should be emailed to: If you are accepted into the program you will receive information on registering for the program.

Financial Assistance
When planning to attend a continuing education course or program, an important consideration is the cost, which may include tuition, books and travel. With Molloy College, Division of Continuing Education and Professional Studies, various financial assistance options are available to help students afford tuition. Since most Continuing Education courses do not lead to a college degree, they are not eligible for the traditional forms of financial aid, such as TAP and Pell. Some private lenders will help you finance continuing education and certificate programs. Click here to find out about student loans, re-training for those who are unemployed, employer and union vouchers and vocational services for individuals with disabilities. 

Spring 2024 Schedule

20 Fridays, March 15 - August 9 (No class 5/24 & 7/5), 6:00pm - 9:00pm,  online with Zoom

Tuition: $2,995.00

Questions? Contact Vanessa Podesta at: