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.
Rely on Clinical Documentation Improvement Desk Reference for ICD-10-CM and Procedure Coding 2024 to improve your documentation process.
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 documentation will more than ever translate into reimbursement gained or lost.
Exclusive Optum Edge features found in this Optum360 CDI coding guide:
- Optum Edge — HCC and QPP icon alerts added at the code level to aid in coding.
- Optum Edge — A list of medications is noted for codes that are deemed applicable.
- Optum Edge — The “Clinician’s Checklist for ICD-10-CM.” Make copies of this handy trifold, pocketsize card for every clinician. Provides powerful documentation tips for the 5 most important chronic and acute conditions.
Additional features and benefits of Clinical Documentation Improvement Desk Reference for ICD-10-CM and Procedure Coding include:
- 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. Documentation training 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.
- Terminology Translator. This unique feature is 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.