CDEI Study Guide

The Certified Documentation Expert – Inpatient (CDEI) Study Guide is designed to help you prepare for the CDEI certification exam. This comprehensive guide covers key concepts and best practices for clinical documentation integrity (CDI) in the inpatient setting, ensuring accurate medical record documentation, regulatory compliance, and proper reimbursement.

The study guide provides an in-depth review of essential topics, including:

  • The fundamentals of clinical documentation integrity (CDI) and its impact on quality reporting and reimbursement.
  • Guidelines for compliant inpatient documentation, including physician queries, principal diagnosis selection, and complication/comorbidity (CC) and major complication/comorbidity (MCC) capture.
  • ICD-10-CM and ICD-10-PCS coding principles as they relate to inpatient documentation and severity of illness (SOI) and risk of mortality (ROM) reporting.
  • Healthcare regulations and compliance considerations, including CMS guidelines, value-based purchasing, and audit risks.
  • Strategies for physician education, query optimization, and collaboration with healthcare teams to improve documentation accuracy.

This study guide is an excellent resource for anyone preparing for the CDEI exam and seeking to enhance their expertise in inpatient clinical documentation. It includes key terms, coding examples, and review questions to reinforce learning.




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