PDF-(BOOS)-ICD-10-CM Documentation 2020: Essential Charting Guidance to Support Medical Necessity

ICD10CM 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 ICD10 the new edition focuses on the key role proper documentation plays in supporting medical necessityICD10CM Documentation 2020 brings coders and physicians together to ensure documentation success identifying all ICD10CM documentation requirements using detailed checklistsDesigned for use alongside an ICD10CM 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 nonfacility and facility coders The chapter organization mirrors the structure of codebooks and all guidance is geared toward the process of code decisionmaking In addition exercises and quizzes test knowledge and understanding of key points throughout the bookFEATURES AND BENEFITS    New codes revisions and deletions plus guideline updates for 2020 final 2020 changes will be integrated into every pertinent chapter checklist scenario and quiz    Detailed fullpage anatomy illustrations for better interpretation of clinical notes    Checklists to identify documentation elements for categories subcategories and codes    Checklists for specialtyspecific documentation to review current records and identify any documentation deficiencies    ICD10CM documentation scenarios display documentation requirements with important elements highlighted    CDI checklists identify common documentation deficiencies faced when coding COPD Pneumonia and SepsisSIRS    Glossary of Medical Terminology    Scenarios illustrate required documentation in ICD10CM with additional ICD10 requirements highlighted so readers can understand where the documentation will appear in common coding scenarios based on reallife health care encounters    End of chapter quizzes dive into coding practice with the conditions discussed in each chapter. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, . C-CDI. Manager. Accretive Health. Medical Necessity. Medical Necessity . Fundamental to Medicine. Integral to Revenue Cycle. Basis for healthcare delivery transformation. HPR . 451. Where does . documentation. fit into the TR process?. Assessment?. Planning??. Implementation???. Evaluation????. ??????????????????????????????????????. Documentation – who needs it?. TR/RT. Patient Documentation. Super User Training. 1. Upon completion of training, the learner will demonstrate ability to: . 1. Share the vision for the changes in nursing documentation. 2. . Identify . EMS Documentation Uses. Legal record. Continuity of care with hospital. Internal quality assurance. Billing record. Today’s Environment. Government focus on fraud. Increased audits. Legally collecting every dollar . An Overview of Key . C. omponents. Presented by . BHM Healthcare Solutions. Learning Objectives. Upon completion of this presentation participants will have a thorough knowledge of Medical Necessity Criteria including emerging definitions. Patient Documentation. Super User Training. 1. Upon completion of training, the learner will demonstrate ability to: . 1. Share the vision for the changes in nursing documentation. 2. . Identify . RCPA Conference. October 8, 2014. Agenda . Behavioral Health Services Cultural Overview. Current Regulatory Environment – New Compliance Challenges. Function of the Progress Note. Defensive Maneuvers – Audit Proof Documentation. Jason Hess, LCAC. Executive Director. Heartland RADAC. How do I get those darned insurance companies to listen?!?. Alternative Title. 4 Essential Elements . to Good Counseling. WEG . W. armth – Caring, Supportive, Welcoming. iagnostic and/or therapeutic services provided and/orthat services provided have been accurately reportedII GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATIONThe principles of documentation listed bel page 1 of 8Determination for Bariatric Surgery31ese Guidelines for Medical Necessity Determination 147Guidelines148 identify the clinical information that MassHealth needs to determine medical necessi 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 BENEFITSNew codes, revisions and deletions, plus guideline updates for 2021 — final changes will be integrated into every pertinent chapter, checklist, scenario and quizDetailed, full-page anatomy illustrations — for better interpretation of clinical notesChecklists to identify documentation elements — for categories, subcategories and codesChecklists for specialty-specific documentation — to review current records and identify any documentation deficienciesICD-10-CM documentation scenarios — display documentation requirements with important elements highlightedCDI checklists — identify common documentation deficiencies faced when coding COPD, Pneumonia and Sepsis/SIRSGlossary of Medical TerminologyScenarios — 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 encountersEnd of chapter quizzes — dive into coding practice with the conditions discussed in each chapter 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 2020 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 2020 — final 2020 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 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 BENEFITSNew codes, revisions and deletions, plus guideline updates for 2021 — final changes will be integrated into every pertinent chapter, checklist, scenario and quizDetailed, full-page anatomy illustrations — for better interpretation of clinical notesChecklists to identify documentation elements — for categories, subcategories and codesChecklists for specialty-specific documentation — to review current records and identify any documentation deficienciesICD-10-CM documentation scenarios — display documentation requirements with important elements highlightedCDI checklists — identify common documentation deficiencies faced when coding COPD, Pneumonia and Sepsis/SIRSGlossary of Medical TerminologyScenarios — 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 encountersEnd of chapter quizzes — dive into coding practice with the conditions discussed in each chapter 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