ICD-10-CM Documentation 2018: Essential Charting Guidance to Support Medical Necessity

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, this new edition focuses on the key role proper documentation plays in supporting medical necessity.

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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 2018 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.

Accurate coding requires access to the up-to-date ICD-10-CM code set found in this resource. Don’t rely on outdated information!

Features and Benefits

New codes, revisions and deletions, plus guideline updates for 2018 — final 2018 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