Clinical documentation integrity (CDI) is not about how to code in ICD-10-CM or CPT. CDI is about knowing what to look for in medical records and 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 2027 to improve your documentation process.
Clinicians’ documentation, with adequate clinical detail, has never been more important in the correct code selection process. This 2027 edition has been updated with the relevant code changes.
Exclusive Optum Edge features found in this Optum CDI coding guide:
- Optum Edge — HCC and QPP Icons. Symbols at the code level identify codes associated with CMS quality payment program (QPP) measures, and CMS hierarchical condition categories (HCC) alert you to assist in code selection.
- Optum Edge — Medication Lists. Locate medications that may be applicable for medical conditions to assist you in the documentation review.
Additional features and benefits of Clinical Documentation Improvement Desk Reference for ICD-10-CM and Procedure Coding include:
- Diagnoses Diagnosis and Procedure Documentation. Review documentation requirements for CPT®, HCPCS, and ICD-10-CM coding. Enhance your code selection accuracy for all three coding systems.
- Physician Documentation Training. Show physicians what they need to document. Training includes 21 detailed checklists for the most common and complex medical conditions. Teach them what you need for optimal code assignment.
- Key Terms. Confirm accurate code selection for every chapter of ICD-10-CM.
- Terminology Translator. Be confident you are using correct terminology with this unique feature included at the code level.
- Streamline the Query Process. Show physicians which medical terms are essential to assigning ICD-10-CM and CPT codes. Includes best practice query forms that get results without unduly influencing clinicians.
CPT is a registered trademark of the American Medical Association.