Clinical documentation improvement (CDI) is not about how to code in ICD-10-CM or CPT; CDI is knowing what to look for in medical records, as well as how to ask for clarification and get ongoing changes to the notes and comments provided by physicians.
Important Note: The greater number of ICD-10-CM diagnostic codes means an even bigger need for detailed clinical documentation. Making the right code selection requires having adequate clinical detail and, under ICD-10-CM, clinician's documentation will more than ever translate into reimbursement gained or lost.
Key features and benefits of this Optum360 CDI coding guide:
- Optum360 Edge—HCC and QPP icon alerts added at the code level to aid in coding.
- Optum360 Edge—A list of medications is noted for codes that are deemed applicable.
- Optum360 Edge—The “Clinician’s Checklist for ICD-10-CM.” Make copies of this handy tri-fold, pocketsize card for every clinician. Provides powerful documentation tips for the 5 most important chronic and acute conditions.
- Diagnoses and Procedures—Covers documentation for CPT, HCPCS, and ICD-10-CM coding. Enhance your code selections with documentation requirements for all three coding systems.
- Physician Documentation Training. Show physicians what they need to document. Includes 21 detailed documentation checklists for the most common and complex medical conditions.
- Don’t teach your clinicians to code ICD-10-CM. Instead show them what you need for optimal code assignment.
- See key terms. Confirm accurate code selection for every chapter of ICD-10-CM.
- Know when ICD-10-CM differs dramatically from ICD-9-CM. Alerts and warnings in the text of this book call your attention to situations where ICD-10-CM coding protocols are different from ICD-9-CM and significantly affect code choices.
- Terminology Translator. This unique feature is now included at the code level.
- Streamline the query process. Show physicians which medical terms are essential to assigning codes in ICD-10-CM. Includes best practice query forms that get results without unduly influencing clinicians.
CPT is a registered trademark of the American Medical Association.