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ICD-10-CM Documentation 2021: Essential Charting Guidance to Support Medical Necessity identifies the more detailed ICD-10-CM documentation requirements and information vital to successful ICD-10-CM coding. This collection of best practices provides tools for an effective documentation analysis along with a corrective action plan.
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 2021 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
Binding and Size: Softbound, 8½" × 11"
Page Count: Approx. 525