Clinical documentation improvement (CDI) is not about how to code in ICD-10 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 codes selection requires having adequate clinical detail, and under ICD-10, clinician's documentation will—more than ever—translate into reimbursement gained or lost.
Key Features and Benefits
- Covers documentation for CPT and HCPCS coding, and ICD-10-CM. Enhance your code selections with documentation requirements for all three coding systems.
- Includes the unique "ICD-9 to ICD-10 Mapping" tables that maps clinical terms. An exclusive documentation resource that maps ICD-9-CM clinical terminology to the associated ICD-10-CM terms to speed finding the correct code.
- Teach clinicians with the "Clinician's Checklist for ICD-10-CM." Make copies of this handy tri-fold, pocketsize card for every clinician. Provides powerful documentation tips for the 5 most important chronic and acute conditions.
- Physician Documentation Training. Show physicians what they need to document. Includes 21 detailed documentation checklists for the most common and complex medical conditions.
- Don't teach your clinicians to code ICD-10-CM. Instead show them what you need for optimal code assignment.
- See key terms. Confirm accurate code selection for every chapter of ICD-10-CM.
- Know when ICD-10-CM differs dramatically from ICD-9-CM. Alerts and warnings in the text of this book call your attention to situations where ICD-10-CM coding protocols are different from ICD-9-CM and significantly affect code choices.
- Streamline the query process. Show physicians which medical terms are essential to assigning codes in ICD-10-CM. Includes best practice query forms that get results without unduly influencing clinicians.
CPT® is a registered trademark of the American Medical Association.