ICD-10-CM Documentation 2019: Essential Charting Guidance to Support Medical Necessity PDF

ICD-10-CM Documentation 2019: Essential Charting Guidance to Support Medical Necessity PDF 

by American Medical Association (Author)

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 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 conditions discussed in each chapter 

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