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ICD-10-CM Documentation: Essential Charting Guidance to Support Medical Necessity 2019
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About ICD-10-CM Documentation: Essential Charting
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 2019 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.Features and Benefits - New codes, revisions and deletions, plus guideline updates for 2019 -- final 2019 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 wi
