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Bridging the Gap Between Clinical Documentation and Coding
All health care providers have a duty to ensure that all claims submitted to federal health care programs are true and accurate. This class will help coders work with providers to assess and gather the information needed in documentation to support appropriate code assignments.
Class Highlights:
- Review clinical documentation requirements for ICD-10-CM
- Identify problems with clinical documentation, such as copy/paste/cloning
- Learn strategies for maintaining effective communication and positive professional interaction between clinicians and coders
- Learn how to query providers to extract complete/correct information from the documentation
- Explanation of 7th character usage, and difference between initial and subsequent
- Learn how to minimize use of unspecified codes.
- Focus on the documentation impact of patient quality care
- Establish guidelines for documenting and coding of medical records to their greatest level of specificity
- Review the scope and steps for an effective compliance plan
- Learn what to do if you have information about fraud or abuse in your organization
- Engage in hands-on practice with documentation examples and writing different forms of queries
See the full course description here.
Target Audience
This is an intermediate-level course that will help medical coders and auditors work with providers to gather and assess the information needed in documentation to support appropriate code assignments. Consultants, compliance officers and office managers may also benefit. This content assumes knowledge of outpatient coding and reimbursement.
What to Bring
Registration includes a digital course manual. Participants will need a current ICD-10-CM code set manual.
Full Schedule
Program times are Central unless otherwise noted.
| Session | Date | Time | Instructor | |
| 1 | November 04, 2025 | 11:00 am - 2:00 pm | Jan Hailey | |
| Fee: $239.00 | Register | |||
Can't attend a live session? Register anyway and you'll receive a link to the recording by the next business day.
CEUs:
| PMI | 3 |
About the Presenter
Jan Hailey MHL, CMC, CMCO, CMIS, CMOM, CMCA E/M
Jan Hailey has more than 30 years of experience in healthcare. She is proficient in administration, coding, and billing roles, and teaches medical office professionals around the country how to excel in their careers. Jan has also been instrumental in the development of PMI's Workforce Initiatives program.
Jan's affinity for teaching has helped countless healthcare providers and medical office professionals over the years. During her expansive career, she has served as Director of Quality for Saint Joseph Physician Network located in Mishawaka, IN, and Director of Care Management with Select Health Network, an entity of Saint Joseph Health System. As Care Management Director, Jan led the physician network and comprehensive interdisciplinary team across the health system working closely with providers, management, staff, community, and payers to develop strategies for process improvement, gap closures, and patient experience. She developed a documentation improvement program and a Hierarchical Condition Category (HCC) coding education program to predict future healthcare utilization by accurately reporting patient complexity.
Prior to joining Saint Joseph, Jan was the Director of Quality, Coding, and Compliance for one of the largest health systems in Northern Indiana. She has a Master of Health Leadership and four professional certifications in office management, coding, insurance processing, and compliance. She is a member of WPS Government Health Administrators (Medicare) Provider Outreach and Advisory Group.