Education and Training  . . . for HIM and CDI

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Leave a Comment

Education and Training  . . . for HIM and CDI

For those of us within the Health Information Management (HIM) profession and even Clinical Documentation Integrity (CDI) profession one of the main aspects to our jobs, our careers, is in fact obtaining “Education and Training”. Although related to each other, education and training are not exactly the same.

First let’s discuss “education” and its’ meaning in the context of HIM and CDI. Education is the receiving or even giving of instruction, resulting in an acquired knowledge, and/or reasoning. Think of the analysis of medical records; and the instruction on the translation of clinical documentation into coded data, while applying coding conventions, instructions, and guidelines, resulting in an acquired knowledge and reasoning of clinical coding, this is what HIM Coding does.

Now lets’ understand the “training” piece, which is the application of one’s knowledge, reasoning using practice and skills. Simple put it’s the practice and function of the task or job. When you receive a coding instruction or guidance from AHA Coding Clinic on ICD-10-CM/PCS you read, comprehend, and understand. Then when you perform the function or task of “coding” or “CDI” or even conduct auditing you apply the knowledge that you gained through the reading, comprehending, and understanding.

Ongoing education and training is vital for HIM and CDI in that we have to learn and apply annual coding changes, guideline changes and revisions (ICD-10-CM/PCS, CPT), quarterly AHA Coding Clinic advice. monthly AMA CPT Assistant guidance, annual payer changes, new clinical information and more. So, there is always lots of subjects and/or topics to learn about. In fact, monthly educational in-services should be considered for any department or healthcare organization. Even with a one-hour webinar or face to face in-service that is created as an educational presentation, that presentation should contain at the minimum the following:

  • Title
  • Speaker Bio
  • Disclaimer
  • Goals/Objectives
  • Background
  • Content
  • Examples with practice
  • Next steps
  • Summary
  • Q&A
  • Thank you and contact information
  • References/Resources

When receiving education and training from an outside company or service, be sure to ask for a brief outline and/or sample of the education and training material that will be presented or delivered. If you feel it is not going to provide all that you are looking for, be sure to let the company know this, so adjustments can be made. Also inquire regarding continuing education units or CEUs, for professional credit.

New employee education and training is vital to start a new position off on the right foot. Employers or departments should have in place a well-thought-out new employee orientation which includes education regarding the specific work and then followed immediately by hands-on training or practice. Take a look at your own new employee education and training or orientation material, ensure it is meeting the needs and the outcomes for that new worker.

The Office of the Inspector General (OIG) in prior healthcare compliance guidance included education and training in their MUST HAVE seven (7) key elements of a compliance program. Here’s what the OIG says: the development and implementation of regular, effective education and training programs for all affected employees. I for one really take this to heart and as an HIM Coding professional, I believe we all should do that same. Keep in mind that having BOTH education AND training, one can continue to learn, grow, and improve our work and our skills. Of course, the result of that learning effort brings work improvements, productivity, enhanced knowledge, innovation and certainly job satisfaction but also “compliance!”.

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