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.

• 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

The American Medical Association has promoted scientific advancement, improved public health and protected the patient-physician relationship since its establishment in 1847. The AMA is the premier national organization dedicated to empowering the nation's physicians to provide safer, higher quality and more efficient care to patients and communities. For more than 50 years, the AMA, in drawing upon its deep expertise and resources, has authored and published books, data files and online resources that answer the needs of today's busy physicians and their staff. The AMA product line includes titles on CPT (R), HCPCS and ICD-10 coding, as well as reimbursement, practice management, disability evaluation, impairment, HIPAA and electronic health records.