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, 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Don't rely on outdated information!Features and BenefitsNew codes, revisions and deletions, plus guideline updates for 2018 - final 2018 changes will be integrated into every pertinent chapter, checklist, scenario and quizDetailed, full-page anatomy illustrations - for better interpretation of clinical notesChecklists to identify documentation elements - for categories, subcategories and codesChecklists for specialty-specific documentation - to review current records and identify any documentation deficienciesICD-10-CM documentation scenarios - display documentation requirements with important elements highlightedCDI checklists - identify common documentation deficiencies faced when coding COPD, Pneumonia and Sepsis/SIRSGlossary of Medical TerminologyScenarios - 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 encountersEnd of chapter quizzes - dive into coding practice with the conditions discussed in each chapter