Clinical Documentation Improvement Desk Reference For Icd 10 Cm Procedural Coding

Clinical documentation improvement (CDI) is not about how to code in ICD-10-CM or CPT. CDI is knowing what to look for in medical records, as well as how to ask for clarification and get ongoing changes to the notes and comments provided by physicians. Important Note: The greater number of ICD-10-CM diagnostic codes means an even bigger need for detailed clinical documentation. Making the right code selection requires having adequate clinical detail, and under ICD-10-CM, clinician's documentation willmore than evertranslate into reimbursement gained or lost.

Clinical documentation improvement (CDI) is not about how to code in ICD-10-CM or CPT. CDI is knowing what to look for in medical records, as well as how to ask for clarification and get ongoing changes to the notes and comments provided by physicians. Important Note: The greater number of ICD-10-CM diagnostic codes means an even bigger need for detailed clinical documentation. Making the right code selection requires having adequate clinical detail, and under ICD-10-CM, clinician's documentation willmore than evertranslate into reimbursement gained or lost.

Take charge of ICD-10 documentation requirements The implementation of ICD-10 brings with it new documentation requirements that will have a significant impact on the work of your CDI team. The higher degree of specificity of information needed to code accurately will have a direct correlation to reimbursement and compliance. CDI specialists need a firm understanding of the new code set, and the rules that govern it, to obtain the appropriate level of documentation from physicians. The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only book that addresses ICD-10 from the CDI point of view. Written by CDI experts, it explains the new documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. You'll find the specific documentation requirements to appropriately code conditions such as heart failure, sepsis, and COPD. Learn from your peers The Clinical Documentation Improvement Specialist's Guide to ICD-10 includes case studies from two hospitals that have already begun ICD-10 training so you can use their timelines as a blue print to begin your organization's training and implementation. ICD-10 implementation happens in 2013. It's not too soon to start developing the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. Benefits: * Tailored exclusively for CDI specialists * Side-by-side comparison of what documentation is necessary now v. what will be required starting October 1, 2013 * Timelines to train physicians in new documentation requirements to ensure readiness by implementation date * Strategies and best practices to ensure physician buy-in

The greater number of ICD-10-CM diagnostic codes means an even bigger need for detailed clinical documentation. Making the right codes selection requires having adequate clinical detail, and under ICD-10, clinician's documentation will-more than ever-translate into reimbursement gained or lost. The quality of clinical documentation is a longstanding challenge. This manual provides the resources you need to enhance coding through clinical documentation improvement for ICD-10-CM.

The greater number of ICD-10-CM diagnostic codes means an even bigger need for detailed clinical documentation. Making the right codes selection requires having adequate clinical detail, and under ICD-10, clinician's documentation will-- more than ever--translate into reimbursement gained or lost. The quality of clinical documentation is a longstanding challenge. This manual provides the resources you need to gain physician cooperation and to enhance coding through clinical documentation improvement for ICD-10-CM. Important Note: Clinical documentation improvement (CDI) is not about how to code in ICD-10. CDI is knowing what to look for in medical records, as well as how to ask for clarification and get ongoing changes to the notes and comments provided by physicians.

It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.

Coding is a skill requiring in-depth knowledge of anatomy, physiology, new technology, coding guidelines, and documentation issues. Both novice and experienced coders will have questions--so when the code book and guidelines do not provide the answers, the Coders' Desk Reference for ICD-9-CM Procedures will. With this comprehensive resource on all the ICD-9-CM procedure codes, you can improve coding confidence by gaining a better understanding of the technical terminology and intricacies of procedures, along with essential coding tips, before selecting a code..

The Coders' Desk Reference for ICD-10-PCS Procedures addresses the challenge of translating common procedural nomenclature used by providers to the corresponding ICD-10-PCS coding terminology. Because provider documentation often does not reflect the precise terminology found in ICD-10-PCS, correct procedure coding is dependent on the ability of the coder to translate common procedural terminology to the appropriate procedural terminology of ICD-10-PCS. This resource is organized by common procedural nomenclature used in the hospital setting and then linked to the related root operation table(s); the procedure is described in layman's terms, translated to ICD-10-PCS root operation terminology, and the corresponding root operation table(s) is identified.