ICD-10-CM Documentation: 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, the new edition focuses on the key role proper documentation plays in supporting medical necessity. ICD-10-CM Documentation 2017 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 Don't rely on outdated information!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! More than 2,500 new codes, revisions and deletions, plus guideline updates proposed for 2017 - final 2017 changes will be integrated into every pertinent chapter, checklist, scenario and quiz.* 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 - 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 conditionsdiscussed in each chapter. Target Audience Coding professionals, physicians, allied health professionals, medical office staff, coding consultants, trainers, insurance practitioners, hospital billing offices (inpatient and outpatient) and insurance carrier staff.