This unique manual shows what the medical record must contain for correct coding and billing of specific medical and diagnostic services and procedures. It provides coders and anyone concerned about coding with an auditor’s perspective on the clinical detail, regulatory instructions, and coding protocol needed for code assignment. Avoid the devastating effects of outside audits and reviews with this detailed coding tool.

Key Features and Benefits

• Optum Edge — Get online access to customizable audit worksheets. Protect your revenuecritical services and procedures.

• Conduct skilled internal audits. Ensure proper reimbursement.

• Differentiate between similar procedures. Compare and contrast seemingly similar, but different, procedures.

• Completely updated for 2023 code set and regulatory changes.

• Increase Revenue. Learn the appropriate way to report telehealth services.

• Provides coders with an auditor’s perspective. Know the clinical detail, regulatory instructions, and coding best practices needed for code assignment.

• Know what information needs to be in the medical record and on the claim form to capture appropriate reimbursement.

• Know the key terms that need to be mentioned in the medical record to support code assignment.

• See the medical conditions that are indicated for diagnostic, therapeutic, and surgical purposes.

• Gain valuable code intelligence. Confirm correct code assignment.

• Train your staff. This resource is thorough and can easily be used to train staff how to assign codes appropriately.

• Correct modifier assignment. Modifier decision-making trees assist with assigning correct modifiers.

• Supports Best Practices.

The ICD-10-CM Fast Finders utilize our Optum360 Xpress Coding Matrix with ICD-10-CM codes presented by specialty and updated with the 2022 valid ICD-10-CM codes, in an easy-touse table format that maximizes the number of codes contained in the fast finder and also simplifies code selection. These convenient and reliable coding tools provide complete and valid code selections at your fingertips.

Use this coding tool to determine the most specific ICD-10-CM codes for your specialty – codes that accurately identify the patient condition and level of severity as well as support medical necessity.

The ICD-10-CM Fast Finders utilize our Optum Xpress Coding Matrix with ICD-10-CM codes presented by specialty and updated with the 2023 valid ICD-10-CM codes, in an easy-to-use table format that maximizes the number of codes contained in the fast finder and also simplifies code selection. These convenient and reliable coding tools provide complete and valid code selections at your fingertips. 

Use this coding tool to determine the most specific ICD-10-CM codes for your specialty – codes that accurately identify the patient condition and level of severity as well as support medical necessity.

• Optum Edge — Optum Xpress Coding Matrix (designed and used exclusively by Optum). Our easy-to-use, streamlined tables present valid code options for each condition.
• Optum Edge — Compact 6” x 9” accordion format. More codes, less space in our compact accordion format which provides 8–10 pages of specialty specific codes.
• Optum Edge — Alphabetically organized tables. Body systems and main diagnostic terms are organized alphabetically in tables that contain a comprehensive list of valid out to the 4th, 5th, 6th or 7th characters. 
• Complete and comprehensive coverage by specialty. The Fast Finders provide commonly used ICD-10-CM codes for each specialty as well a comprehensive list of valid codes within diagnostic categories for your specialty. 
• Valid codes. Updated with ICD-10-CM codes for 2023, code directly from the tables contained in the Optum Xpress Coding Matrix with confidence. 
• Coding Instructions. Code first, use additional code and other coding instructions are included in the tables to ensure correct sequencing of all relevant codes.
• Productivity tool. The logical look-up format makes finding the right code easier.

Convenient work flow coding tool. Rely on one at every workstation. 

The ICD-10-CM Fast Finders utilize our Optum360 Xpress Coding Matrix with ICD-10-CM codes presented by specialty and updated with the 2022 valid ICD-10-CM codes, in an easy-touse table format that maximizes the number of codes contained in the fast finder and also simplifies code selection. These convenient and reliable coding tools provide complete and valid code selections at your fingertips.

Use this coding tool to determine the most specific ICD-10-CM codes for your specialty – codes that accurately identify the patient condition and level of severity as well as support medical necessity.

The ICD-10-CM Fast Finders utilize our Optum Xpress Coding Matrix with ICD-10-CM codes presented by specialty and updated with the 2023 valid ICD-10-CM codes, in an easy-to-use table format that maximizes the number of codes contained in the fast finder and also simplifies code selection. These convenient and reliable coding tools provide complete and valid code selections at your fingertips. Use this coding tool to determine the most specific ICD-10-CM codes for your specialty – codes that accurately identify the patient condition and level of severity as well as support medical necessity.

Key Features and Benefits

• Optum Edge — Optum Xpress Coding Matrix (designed and used exclusively by Optum). Our easy-to-use, streamlined tables present valid code options for each condition.

• Optum Edge — Compact 6” x 9” accordion format. More codes, less space in our compact accordion format which provides 8–10 pages of specialty specific codes.

• Optum Edge — Alphabetically organized tables. Body systems and main diagnostic terms are organized alphabetically in tables that contain a comprehensive list of valid out to the 4th, 5th, 6th or 7th characters.

• Complete and comprehensive coverage by specialty. The Fast Finders provide commonly used ICD-10-CM codes for each specialty as well a comprehensive list of valid codes within diagnostic categories for your specialty.

• Valid codes. Updated with ICD-10-CM codes for 2023, code directly from the tables contained in the Optum Xpress Coding Matrix with confidence.

• Coding Instructions. Code first, use additional code and other coding instructions are included in the tables to ensure correct sequencing of all relevant codes.

• Productivity tool. The logical look-up format makes finding the right code easier.

• Convenient work flow coding tool. Rely on one at every workstation. 

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

• 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.

• 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.

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 documentation will more than ever translate into reimbursement gained or lost.

The Coders’ Desk Reference for ICD-10-CM Diagnoses provides thousands of clinical descriptions of diseases, disease processes, injuries, poisonings, and other conditions to help both novices and seasoned coders attain the knowledge and skill necessary to accurately identify and assign the most specific ICD-10-CM diagnosis code for each documented condition.

With these clinical definitions and focus points, you can reduce coding errors and improve coding confidence by gaining a better understanding of the clinical meanings behind the codes.

Coders at all experience levels may have questions when the 2022 HCPCS code changes go into effect, and the Coders’ Desk Reference for HCPCS Level II is the book to keep close by to find the answers needed.

With this one-of-a-kind, comprehensive resource on all the codes for 2022, users can reduce coding errors and improve coding confidence by referencing more than 3,000 HCPCS codes with 2,000 lay descriptions, find answers to frequently asked questions, and obtain other helpful guidance before assigning a code.

The Coders’ Desk Reference for Procedures is a comprehensive resource for all 2022 CPT® codes. This all-inclusive tool helps identify the minute differences between, and components of, similar CPT® codes.

You will code more accurately from operative reports and produce cleaner claims the first time by improving your understanding of the clinical meanings behind the codes and checking billing and coding information for Medicare.

The Coders’ Desk Reference for ICD-10-PCS Procedures addresses the challenge of translating common procedural nomenclature used by providers to the corresponding ICD-10-PCS coding terminology. Correct procedure coding is dependent on the ability of the coder to translate the terminology in provider documentation to the appropriate procedural terminology of ICD-10-PCS.

This resource is organized by common procedural nomenclature used in the hospital setting and linked to the related root operation table(s); the procedure is described in layman’s terms, translated to ICD-10-PCS root operation terminology, and the corresponding root operation table(s) is identified.

The Coders’ Desk Reference for ICD-10-CM Diagnoses provides thousands of clinical descriptions of diseases, disease processes, injuries, poisonings, and other conditions to help both novices and seasoned coders attain the knowledge and skill necessary to accurately identify and assign the most specific ICD-10-CM diagnosis code for each documented condition. With these clinical definitions and focus points, you can reduce coding errors and improve coding confidence by gaining a better understanding of the clinical meanings behind the codes.

Key Features and Benefits

• Optum Edge — More clinical descriptions and focus points. Expanded with clinical descriptions and focus points for new and changed 2023 codes as well as existing ICD-10-CM codes.

• Optum Edge — Illustrations at the code level. Often an illustration is needed to enhance understanding. Illustrations of pertinent anatomy and pathological changes related to the disease process are included as a visual aid.

• Optum Edge — Code level clinical description. Code level descriptions are provided for select diseases, injuries, symptoms, other factors influencing health status, and other reasons for contact with healthcare providers.

• Optum Edge — Clinical focus points. Improve overall coding accuracy with additional information for complex diagnoses and injuries that require an understanding of related codes and conditions that might better describe the documented condition.

• Alphanumeric organization by ICD-10-CM code. Locate codes quickly with a resource developed to work hand-in-hand with your Optum ICD-10-CM codebook.

• Enhance understanding of ICD-10-CM. Understanding the clinical condition captured by each code is essential to correct code assignment, and this resource is designed to explain and highlight differences between codes that may appear similar at first glance.

• Designed for both novices and seasoned coders. Coders of every skill level find that these clinical descriptions enhance understanding of ICD-10-CM.

The Coders’ Desk Reference for ICD-10-CM Diagnoses provides thousands of clinical descriptions of diseases, disease processes, injuries, poisonings, and other conditions to help both novices and seasoned coders attain the knowledge and skill necessary to accurately identify and assign the most specific ICD-10-CM diagnosis code for each documented condition.

With these clinical definitions and focus points, you can reduce coding errors and improve coding confidence by gaining a better understanding of the clinical meanings behind the codes.