Essential charting guidance to support medical necessity
ICD-10-CM requires very specific documentation in order to correctly choose diagnostic codes, a skill that both coders and physicians must master to code successfully.
The ICD-10-CM Documentation Trainer brings coders and physicians together to ensure documentation success, identifying all additional ICD-10-CM documentation requirements using detailed checklists.
Designed for use alongside an ICD-10-CM code manual, this critical training guide provides all the tools necessary to conduct an effective documentation analysis and create a corrective action plan, making it ideal for both non-facility and facility coders alike. The chapter organization mirrors the structure of code books and all guidance is geared toward the process of code decision-making. Plus, exercises and quizzes test knowledge and understanding of key points throughout the book.
- NEW! 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 showing required documentation in ICD-10-CM, with additional ICD-10 requirement highlighted—see where the documentation will appear in common coding scenarios based on real life healthcare encounters. The correct codes are included with any applicable guidelines explained.
- End of chapter quizzes—dive right into coding practice with the conditions discussed in each chapter.