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Grand Rounds: Improving Coding Accuracy via Clinical Documentation Improvement Education


By Theodore DeMartini, MD , Assistant Professor, Department of Pediatrics, Penn State Health Milton S. Hershey Medical Center

Objectives (Educational Content) :

1. Describe the importance of documentation for communication, quality monitoring, and reimbursement. 2. Illustrate best documentation practices in the inpatient and outpatient settings. 3. Present a documentation improvement project using education and resource tools.

Target Audience:

General pediatricians, family physicians, nurse practitioners, physician assistants, social workers, psychologists, and nurses.

Identified Gap:

Studies have shown that many providers are not trained to document. Surveys have shown that 80% of pediatric residents believed their documentation training was inadequate.1 26% of emergency medicine residents felt there was sufficient training]ng on documentation and billing with only 9% and 15% stating they could bill correctly or understand coding respectively.2 Adult neurologists 100% of survey respondents felt they had insufficient training in documentation. Note audits performed in that same study showed that only 44% were accurate and 24% had complete information.

Estimated Time to Complete the Educational Activity:

1 hour(s)

Expiration Date for CE/CME Credit:


Method of Participation in the Learning Process:

The learner will view the presentation, successfully complete a post-test and complete an activity evaluation.

Evaluation Methods:

All learners must successfully complete a post-test, as well as an activity evaluation, to claim CE/CME credit.


Theodore DeMartini, MD, has indicated that he has no financial relationships with any ineligible companies.

Accreditation Statement:

Children’s Hospital Medical Center of Akron is accredited by the Ohio State Medical Association to provide continuing medical education for physicians.

CHMCA designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit TM.  Physicians should only claim the credit commensurate with the extent of their participation in the activity.


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Andreae, M. C., Dunham, K., & Freed, G. L. (2009). Inadequate training in billing and coding as perceived by recent pediatric graduates. Clinical Pediatrics, 48(9), 939–944.

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Baksh, A. S. (2018). UTHSC Digital Commons The Importance of Clinical Documentation Improvement The Importance of Clinical Documentation Improvement.

Centers for Medicare & Medicaid Services. (2016). Design and development of the Diagnosis Related Groups (DRG). October, 1–14.

Courtright, E., Diener, I., & Russo, R. (2004). Clinical documentation improvement. The Case Manager, 15(1), 46–49.

Dawson, B., Carter, K., Brewer, K., & Lawson, L. (2010). Chart smart: a need for documentation and billing education among emergency medicine residents? The Western Journal of Emergency Medicine, 11(2), 116–119.

Evans, D. V, Cawse-lucas, J., Ruiz, D. R., Allcut, E. A., Andrilla, C. H. A., & Norris, T. (2015). Family Medicine Resident Billing. Fam Med, 47(3), 175–181.

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