Icd 10 Cm Documentation 2021

These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

ICD-10-CM Documentation 2021 brings coders and physicians together to ensure documentation success, identifying all ICD-10-CM documentation requirements using detailed checklists.

ICD-10-CM requires very specific documentation to correctly choose diagnostic codes, a skill that both coders and physicians must master to code successfully. Moving beyond the transition to ICD-10, the new edition focuses on the key role proper documentation plays in supporting medical necessity.ICD-10-CM Documentation 2021 brings coders and physicians together to ensure documentation success, identifying all ICD-10-CM documentation requirements using detailed checklists.Designed for use alongside an ICD-10-CM codebook, this comprehensive training guide provides all the tools necessary to conduct an effective documentation analysis and to create a corrective action plan, making it ideal for both non-facility and facility coders. The chapter organization mirrors the structure of codebooks and all guidance is geared toward the process of code decision-making. In addition, exercises and quizzes test knowledge and understanding of key points throughout the book.FEATURES AND BENEFITS New codes, revisions and deletions, plus guideline updates for 2021 -- final changes will be integrated into every pertinent chapter, checklist, scenario and quiz Detailed, full-page anatomy illustrations -- for better interpretation of clinical notes Checklists to identify documentation elements -- for categories, subcategories and codes Checklists for specialty-specific documentation -- to review current records and identify any documentation deficiencies ICD-10-CM documentation scenarios -- display documentation requirements with important elements highlighted CDI checklists -- identify common documentation deficiencies faced when coding COPD, Pneumonia and Sepsis/SIRS Glossary of Medical Terminology Scenarios -- illustrate required documentation in ICD-10-CM with additional ICD-10 requirements highlighted so readers can understand where the documentation will appear in common coding scenarios based on real-life health care encounters End of chapter quizzes -- dive into coding practice with the conditions discussed in each chapter

ICD-10-CM Documentation 2021 brings coders and physicians together to ensure documentation success, identifying all ICD-10-CM documentation requirements using detailed checklists.

ICD-10-CM 2021: The Complete Official Codebook provides the entire updated code set for diagnostic coding, organized to make the challenge of accurate coding easier. This codebook is the cornerstone for establishing medical necessity, determining coverage and ensuring appropriate reimbursement. Each of the 21 chapters in the Tabular List of Diseases and Injuries is organized to provide quick and simple navigation to facilitate accurate coding. The book also contains supplementary appendixes including a coding tutorial, pharmacology listings, a list of valid three-character codes and additional information on Z-codes for long-term drug use and Z-codes that can only be used as a principal diagnosis. Official coding guidelines for 2021 are bound into this codebook. FEATURES AND BENEFITS Full list of code changes. Quickly see the complete list of new, revised, and deleted codes affecting the FY 2021 codes, including a conversion table and code changes by specialty. QPP symbol in the tabular section. The symbol identifies diagnosis codes associated with Quality Payment Program (QPP) measures under MACRA. New and updated coding tips. Obtain insight into coding for physician and outpatient settings. New and updated definitions in the tabular listing. Assign codes with confidence based on illustrations and definitions designed to highlight key components of the disease process or injury and provide better understanding of complex diagnostic terms. Intuitive features and format. This edition includes full-color illustrations and visual alerts, including color-coding and symbols that identify coding notes and instructions, additional character requirements, codes associated with CMS hierarchical condition categories (HCC), Medicare Code Edits (MCEs), manifestation codes, other specified codes, and unspecified codes. Placeholder X. This icon alerts the coder to an important ICD-10-CM convention--the use of a "placeholder X" for three-, four- and five-character codes requiring a seventh character extension. Coding guideline explanations and examples. Detailed explanations and examples related to application of the ICD-10-CM chapter guidelines are provided at the beginning of each chapter in the tabular section. Muscle/tendon translation table. This table is used to determine muscle/tendon action (flexor, extensor, other), which is a component of codes for acquired conditions and injuries affecting the muscles and tendons Index to Diseases and Injuries. Shaded guides to show indent levels for subentries. Appendices. Supplement your coding knowledge with information on proper coding practices, risk adjustment coding, pharmacology, and Z codes.

At-a-glance Guide to the 2021 ICD-10-CM Updates in the front of the book lists all new, revised, and deleted codes, providing at-a-glance lookup of the coding changes. Official Guidelines for Coding and Reporting (OGCRs) are listed in full in the Introduction, at the beginning of each chapter, and integrated within the code set, providing easier reference to coding rules when they are needed most. Unique! Full-color anatomy plates (including Netter’s Anatomy art) are included in a separate section for easy reference and cross-referenced within the Tabular List of Diseases and Injuries, to help users understand anatomy and how it may affect choosing codes. Full-color design includes consistent color-coded symbols and text, providing easier access to codes and coding information. American Hospital Association's Coding Clinic® citations include official ICD-10-CM coding advice relating to specific codes and their usage. 191 illustrations provide visual orientation and enhance understanding of specific coding situations. Items are included throughout the Tabular List to ensure accurate coding, providing additional information on common diseases and conditions. Additional elements within specific codes define terms and add coding instructions relating to difficult terminology, diseases and conditions, or coding in a specific category. Symbols and highlights draw attention to codes that may require special consideration before coding, including: new, revised, and deleted Unacceptable Principle Diagnosis Codes that call for the use of additional character(s) Includes, Excludes 1 and Excludes 2 Use Additional Unspecified Code First and Code Also Placeholder X symbol reminds users to assign placeholder X for codes less than 6 characters that require a 7th character. Manifestation code symbol identifies conditions for which it is important to record both the etiology and the symptom of the disease. HCC symbol indicates diagnoses in the Tabular List associated with Hierarchical Condition Categories. Age and Sex edits from the Definition of Medicare Code Edits help to ensure accuracy by denoting codes that are used only with patients of a specific age or sex.

At-a-glance Guide to the 2021 ICD-10-CM Updates in the front of the book lists all new, revised, and deleted codes, providing at-a-glance lookup of the coding changes. Official Guidelines for Coding and Reporting (OGCRs) are listed in full in the Introduction, at the beginning of each chapter, and integrated within the code set, providing easier reference to coding rules when they are needed most. Unique! Full-color anatomy plates (including Netter’s Anatomy art) are included in a separate section for easy reference and cross-referenced within the Tabular List of Diseases and Injuries, to help users understand anatomy and how it may affect choosing codes. Full-color design includes consistent color-coded symbols and text, providing easier access to codes and coding information. American Hospital Association's Coding Clinic® citations include official ICD-10-CM coding advice relating to specific codes and their usage. 191 illustrations provide visual orientation and enhance understanding of specific coding situations. Items are included throughout the Tabular List to ensure accurate coding, providing additional information on common diseases and conditions. Additional elements within specific codes define terms and add coding instructions relating to difficult terminology, diseases and conditions, or coding in a specific category. Symbols and highlights draw attention to codes that may require special consideration before coding, including: new, revised, and deleted Unacceptable Principle Diagnosis Codes that call for the use of additional character(s) Includes, Excludes 1 and Excludes 2 Use Additional Unspecified Code First and Code Also Placeholder X symbol reminds you to assign placeholder X for codes less than 6 characters that require a 7th character. CC (Complications & Comorbidities) and MCC (Major CC) symbols identify codes associated with the presence of secondary diagnoses from MS-DRGs, and call attention to CC and MCC exceptions. Hospital Acquired Condition symbol clearly identifies conditions that will always be coded as hospital acquired. Manifestation code symbol identifies conditions for which it is important to record both the etiology and the symptom of the disease. HCC symbol indicates diagnoses in the Tabular List associated with Hierarchical Condition Categories. Age and Sex edits from the Definition of Medicare Code Edits help to ensure accuracy by denoting codes that are used only with patients of a specific age or sex.