ICD-10-CM Documentation 2021: 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 2021 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 2021, final 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