Keep vital information at your fingertips with the new 2021 edition of the #1 best-selling authoritative CDI Pocket Guide. The CDI Pocket Guide by authors Dr. Richard Pinson and Cynthia Tang, now in its 14th edition, is the original and STILL the best resource for coding and clinical documentation integrity. Each year, the authors research, revise, and clarify the content to update the original CDI Pocket Guide. They capture significant changes in clinical diagnostic standards, ICD-10 codes, Official Coding Guidelines, Coding Clinic, and compliance issues and accommodate useful feedback from readers. They also provide the wisdom of their experience as consultants helping hospitals sculpt their documentation and coding practices to their needs. Each CDI Pocket Guide customer will also receive our in-depth, interactive webinars that will keep you informed and further enhance your knowledge and skills. For over a decade, the CDI Pocket Guide has been the essential, go-to resource for anyone involved in coding and CDI – don’t be without it!

For 2021, you will find new key reference topics for COVID-19, liver failure, and others, and updated clinical diagnostic standards and key refinements to topics such as malnutrition, heart failure, chronic kidney disease, and diabetic complications. All FY2021 CMS MCC-CC/DRG updates and latest Coding Clinic advice is incorporated.

• Publisher : Pinson&Tang (January 1, 2020)
• Language: : English
• Format: Spiralbound
• ISBN-10 : 173345943X
• ISBN-13 : 978-1733459433

    Sentinel Injuries

    Burns

    Medical Neglect and Obesity

    Environmental Neglect and Social Determinants of Health

    Supervisory Neglect

    Children Endangered by Drugs

    Psychological Maltreatment

    Interpersonal Violence

    Human Trafficking and Sexual Exploitation via Electronic Media

    Reporting Abuse, Managing Uncertainty, and Other Legal Issues

    Professional Considerations for Those Who Care for the Potentially Abused Child

    Caring for the Child in Out-of-Home Care

    Trauma-Informed Care and Treatment

    Identification of Child Maltreatment

    Evidence-Based Child Abuse and Neglect Prevention Programs

    Creating Change Through Advocacy

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.

Commemorating its 175th anniversary, this new edition of the American Medical Association’s (AMA) Code of Medical Ethics (AMA Code) has undergone another comprehensive update. Much has changed in medicine and society since the AMA Code was created 175 years ago, and the AMA Code has changed as well. The Annotations, an important research and reference tool, in the AMA Code has been significantly updated to include more up-to-date and relevant cases, as well as the removal of outdated cases. To celebrate its 175th anniversary, this new edition of the AMA Code also includes artwork and poetry and literary excerpts—all selected to reflect our society and to highlight the importance of diversity and equity—to reflect the AMA’s mission to promote the art of medicine and its ethos of putting patients first. The only national code of ethics for all physicians, the AMA Code articulates the core values and ethical responsibilities of physicians who are charged with curing the sick when possible and comforting the dying. Hence, its wide recognition as the most authoritative guide for physicians who strive to practice ethically.

This modernized and updated edition of the AMA Code breathes new energy into this living document, while staying true to what it means to be a good physician. The AMA Code is grounded in the nine Principles of Medical Ethics, which are the standards of conduct that define the essentials of ethical behavior for physicians.

While the AMA Code provides essential guidance for professional conduct for physicians, it is also regularly cited as the medical profession’s authoritative voice in legal opinions, journal articles and media outlets. It is an indispensable resource that deserves to be in every physician office, medical library, hospital, and place where the public’s health is promoted.

FEATURES AND BENEFITS

• Updated and increased number of case annotations, offering synopsis of facts and legal issues. focusing on the court’s reference to the AMA Code’s Principle(s) or Opinion(s) and the role it played in their decisions.

• Intuitive topical chapter structure makes finding pertinent ethical guidance easy.

• A uniform format that improves the readability and application of specific guidance.

• Consolidation of previously disparate guidance on related topics that streamlines the AMA Code.

• Use of accepted definitions and consistent terminology that minimize misinterpretation of guidance.

• Inclusion of a new preface to clarify the different levels of ethical obligation in the offered guidance.

The Coders’ Desk Reference for Procedures is a comprehensive resource for all 2023 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.

Key Features and Benefits

• NEW — Place of service codes for E/M services. Review list of CMS-1500 place of service codes with grid of evaluation and management codes linked to the appropriate place of service

• Comprehensive CPT® code listing with CPT® procedure lay descriptions. Eliminate the need for multiple resources with a one-stop resource of more than 8,000 CPT® codes and 6,000 lay descriptions for surgery, laboratory/pathology, radiology, medicine, and evaluation and management codes.

• E/M guidelines. Review components of care needed to determine E/M levels of service, assisting in proper E/M code assignment.

• Modifier definitions and usage rules. Reduce research time and improve coding accuracy with a complete modifier list, accompanied by narrative explanations to ensure proper use of modifiers.

• Procedure eponym crosswalk. Locate eponym definitions and code links in an alphabetically organized section.

• Reimbursement and procedure glossary of terms. Understand terminology often used in medical record documentation and terms used in communications with payers.

• Abbreviations, acronyms, symbols, prefixes, and suffixes. Better understand terms and use these valuable tools for more efficient CPT® coding.

• Anatomical illustrations. Recognize the body sites described in operative reports with helpful illustrations.

Consolidate the coding process with the Coding Companion, your one-stop coding resource developed exclusively for ENT, allergy and pulmonology. This comprehensive and easy-touse guide is updated for 2023 and organized by specialty-specific CPT® codes. Each CPT® code includes its official description and lay description, coding tip, Medicare edits, and relative value units and is cross-coded to common ICD-10-CM diagnosis codes to complete the coding process. Getting to the code information you need has never been so easy.

Key Features and Benefits

• NEW – Evaluation and Management (E/M) Services Guidelines – E/M codes are used every day in your practice. Now with CPT® E/M Guidelines and our Optum Coding Tips, you have all the information you need to select the correct E/M code for the service provided.

• Quickly find information. All the information you need is provided with the CPT® code, including illustrations, lay descriptions, coding tips, clinical terms, Medicare RVUs and IOM references, and commonly associated ICD-10-CM diagnosis codes.

• Procedure code icons – Quickly identify new, revised, add-on, and telemedicine procedure codes, making your coding process for procedures and E/M services quick and efficient.

• ICD-10-CM code icons – Icons identifying male and female only codes, as well as age-related and laterality diagnosis codes.

• Easily determine fees for your practice and reinforce consistency in the charges. Relative value units including the practice, work, and malpractice components with the total RVUs for nonfacility and facility are included.

• CPT® Assistant references. Identifies that an article or discussion of the CPT® code has been in the American Medical Association’s CPT® Assistant newsletter. Use the citation to locate the correct volume.

• Avoid claim denials and/or audits. Medicare payer information includes references to Internet Only Manual (IOM) guidelines, follow-up days, and assistant-at-surgery.

• CCI edits by CPT® and HCPCS procedure code. CPT® and HCPCS procedure codes with their associated CCI edits are provided in a special section. Quarterly updates are available online at Optumcoding.com Product Update / Support page.

Consolidate the coding process with the Coding Companion, your one-stop coding resource developed exclusively for family practice and pediatrics. This comprehensive and easy-to-use guide is updated for 2023 and organized by specialty-specific CPT® codes. Each CPT® code includes its official description and lay description, coding tip, Medicare edits, and relative value units and is cross-coded to common ICD-10-CM diagnosis codes to complete the coding process. Getting to the code information you need has never been so easy.

Key Features and Benefits

• Evaluation and Management (E/M) Services Guidelines – E/M codes are used every day in your practice. Now with CPT® E/M Guidelines and our Optum Coding Tips, you have all the information you need to select the correct E/M code for the service provided.

• Quickly find information. All the information you need is provided with the CPT® code, including illustrations, lay descriptions, coding tips, clinical terms, Medicare RVUs and IOM references, and commonly associated ICD-10-CM diagnosis codes.

• Procedure code icons – Quickly identify new, revised, add-on, and telemedicine procedure codes, making your coding process for procedures and E/M services quick and efficient.

• ICD-10-CM code icons – Icons identifying male and female only codes, as well as age-related and laterality diagnosis codes.

• Easily determine fees for your practice and reinforce consistency in the charges. Relative value units including the practice, work, and malpractice components with the total RVUs for nonfacility and facility are included.

• CPT® Assistant references. Identifies that an article or discussion of the CPT® code has been in the American Medical Association’s CPT Assistant newsletter. Use the citation to locate the correct volume.

• Avoid claim denials and/or audits. Medicare payer information includes references to Internet Only Manual (IOM) guidelines, follow-up days, and assistant-at-surgery.

• CCI edits by CPT® and HCPCS procedure code. CPT® and HCPCS procedure codes with their associated CCI edits are provided in a special section. Quarterly updates are available online at OptumCoding.com Product Update page.

Consolidate the coding process with the Coding Companion, your one-stop coding resource developed exclusively for cardiology, cardiothoracic and vascular surgery specialties. This comprehensive and easy-to-use guide is updated for 2023 and organized by specialty-specific CPT® codes. Each CPT® code includes its official description and lay description, coding tip, Medicare edits and relative value units and is cross-coded to common ICD-10-CM diagnosis codes to complete the coding process. Getting to the code information you need has never been so easy.

Key Features and Benefits

• NEW – Evaluation and Management (E/M) Services Guidelines – E/M codes are used every day in your practice. Now with CPT® E/M Guidelines and our Optum Coding Tips, you have all the information you need to select the correct E/M code for the service provided.

• Quickly find information. All the information you need is provided with the CPT® code, including illustrations, lay descriptions, coding tips, clinical terms, Medicare RVUs and IOM references, and commonly associated ICD-10-CM diagnosis codes.

• Procedure code icons – Quickly identify new, revised, add-on, and telemedicine procedure codes, making your coding process for procedures and E/M services quick and efficient.

• ICD-10-CM code icons – Icons identifying male and female only codes, as well as age-related and laterality diagnosis codes.

• Easily determine fees for your practice and reinforce consistency in the charges. Relative value units including the practice, work, and malpractice components with the total RVUs for non-facility and facility are included.

• CPT® Assistant references. Identifies that an article or discussion of the CPT® code has been in the American Medical Association’s CPT® Assistant newsletter. Use the citation to locate the correct volume.

• Avoid claim denials and/or audits. Medicare payer information includes references to Internet Only Manual (IOM) guidelines, follow-up days, and assistant-at-surgery. CCI edits by CPT® and HCPCS procedure code. CPT® and HCPCS procedure codes with their associated CCI edits are provided in a special section. Quarterly updates are available online at Optumcoding.com Product Update / Support page.

Consolidate the coding process with the Coding Companion, your one-stop coding resource developed exclusively for emergency medicine, urgent care, critical care, and infectious disease. This comprehensive and easy-to-use guide is updated for 2023 and organized by specialty-specific CPT® codes. Each CPT® code includes its official description and lay description, coding tip, Medicare edits, and relative value units and is cross-coded to common ICD-10-CM diagnosis codes to complete the coding process. Getting to the code information you need has never been so easy.

Key Features and Benefits

• Evaluation and Management (E/M) Services Guidelines – E/M codes are used every day in your practice. Now with CPT® E/M Guidelines and our Optum Coding Tips, you have all the information you need to select the correct E/M code for the service provided.

• Quickly find information. All the information you need is provided with the CPT® code, including illustrations, lay descriptions, coding tips, clinical terms, Medicare RVUs and IOM references, and commonly associated ICD-10-CM diagnosis codes.

• Procedure code icons – Quickly identify new, revised, add-on, and telemedicine procedure codes, making your coding process for procedures and E/M services quick and efficient.

• ICD-10-CM code icons – Icons identifying male and female only codes, as well as age-related and laterality diagnosis codes.

• Easily determine fees for your practice and reinforce consistency in the charges. Relative value units including the practice, work, and malpractice components with the total RVUs for nonfacility and facility are included.

• CPT® Assistant references. Identifies that an article or discussion of the CPT® code has been in the American Medical Association’s CPT Assistant newsletter. Use the citation to locate the correct volume.

• Avoid claim denials and/or audits. Medicare payer information includes references to Internet Only Manual (IOM) guidelines, follow-up days, and assistant-at-surgery.

• CCI edits by CPT® and HCPCS procedure code. CPT® and HCPCS procedure codes with their associated CCI edits are provided in a special section. Quarterly updates are available online at OptumCoding.com Product Update page.

Consolidate the coding process with the Coding Companion, your one-stop coding resource developed exclusively for neurosurgery and neurology. This comprehensive and easy-to-use guide is updated for 2023 and organized by specialty-specific CPT® codes. Each CPT® code includes its official description and lay description, coding tip, Medicare edits, and relative value units and is cross-coded to common ICD-10-CM diagnosis codes to complete the coding process. Getting to the code information you need has never been so easy.

Key Features and Benefits

• NEW – Evaluation and Management (E/M) Services Guidelines – E/M codes are used every day in your practice. Now with CPT® E/M Guidelines and our Optum Coding Tips, you have all the information you need to select the correct E/M code for the service provided.

• Quickly find information. All the information you need is provided with the CPT® code, including illustrations, lay descriptions, coding tips, clinical terms, Medicare RVUs and IOM references, and commonly associated ICD-10-CM diagnosis codes.

• Procedure code icons – Quickly identify new, revised, add-on, and telemedicine procedure codes, making your coding process for procedures and E/M services quick and efficient.

• ICD-10-CM code icons – Icons identifying male and female only codes, as well as age-related and laterality diagnosis codes.

• Easily determine fees for your practice and reinforce consistency in the charges. Relative value units including the practice, work, and malpractice components with the total RVUs for nonfacility and facility are included.

• CPT® Assistant references. Identifies that an article or discussion of the CPT® code has been in the American Medical Association’s CPT® Assistant newsletter. Use the citation to locate the correct volume.

• Avoid claim denials and/or audits. Medicare payer information includes references to Internet Only Manual (IOM) guidelines, follow-up days, and assistant-at-surgery.

• CCI edits by CPT® and HCPCS procedure code. CPT® and HCPCS procedure codes with their associated CCI edits are provided in a special section. Quarterly updates are available online at Optumcoding.com Product Update / Support page.

Consolidate the coding process with the Coding Companion, your one-stop coding resource developed exclusively for obstetrics and gynecology. This comprehensive and easy-to-use guide is updated for 2023 and organized by specialty-specific CPT® codes. Each CPT® code includes its official description and lay description, coding tip, Medicare edits, and relative value units and is cross-coded to common ICD-10-CM diagnosis codes to complete the coding process. Getting to the code information you need has never been so easy.

Key Features and Benefits

• NEW – Evaluation and Management (E/M) Services Guidelines – E/M codes are used every day in your practice. Now with CPT® E/M Guidelines and our Optum Coding Tips, you have all the information you need to select the correct E/M code for the service provided.

• Quickly find information. All the information you need is provided with the CPT® code, including illustrations, lay descriptions, coding tips, clinical terms, Medicare RVUs and IOM references, and commonly associated ICD-10-CM diagnosis codes.

• Procedure code icons – Quickly identify new, revised, add-on, and telemedicine procedure codes, making your coding process for procedures and E/M services quick and efficient. • ICD-10-CM code icons – Icons identifying male and female only codes, as well as age-related and laterality diagnosis codes.

• Easily determine fees for your practice and reinforce consistency in the charges. Relative value units including the practice, work, and malpractice components with the total RVUs for nonfacility and facility are included.

• CPT® Assistant references. Identifies that an article or discussion of the CPT® code has been in the American Medical Association’s CPT® Assistant newsletter. Use the citation to locate the correct volume.

• Avoid claim denials and/or audits. Medicare payer information includes references to Internet Only Manual (IOM) guidelines, follow-up days, and assistant-at-surgery.

• CCI edits by CPT® and HCPCS procedure code. CPT® and HCPCS procedure codes with their associated CCI edits are provided in a special section. Quarterly updates are available online at Optumcoding.com Product Update / Support page.

Consolidate the coding process with the Coding Companion, your one-stop coding resource developed exclusively for ophthalmology. This comprehensive and easy-to-use guide is updated for 2023 and organized by specialty-specific CPT® codes. Each CPT® code includes its official description and lay description, coding tip, Medicare edits, and relative value units and is cross-coded to common ICD-10-CM diagnosis codes to complete the coding process. Getting to the code information you need has never been so easy.

Key Features and Benefits

• NEW – Evaluation and Management (E/M) Services Guidelines – E/M codes are used every day in your practice. Now with CPT® E/M Guidelines and our Optum Coding Tips, you have all the information you need to select the correct E/M code for the service provided.

• Quickly find information. All the information you need is provided with the CPT® code, including illustrations, lay descriptions, coding tips, clinical terms, Medicare RVUs and IOM references, and commonly associated ICD-10-CM diagnosis codes.

• Procedure code icons – Quickly identify new, revised, add-on, and telemedicine procedure codes, making your coding process for procedures and E/M services quick and efficient.

• ICD-10-CM code icons – Icons identifying male and female only codes, as well as age-related and laterality diagnosis codes.

• Easily determine fees for your practice and reinforce consistency in the charges. Relative value units including the practice, work, and malpractice components with the total RVUs for non-facility and facility are included.

• CPT® Assistant references. Identifies that an article or discussion of the CPT® code has been in the American Medical Association’s CPT® Assistant newsletter. Use the citation to locate the correct volume.

• Avoid claim denials and/or audits. Medicare payer information includes references to Internet Only Manual (IOM) guidelines, follow-up days, and assistant-at-surgery.

• CCI edits by CPT® and HCPCS procedure code. CPT® and HCPCS procedure codes with their associated CCI edits are provided in a special section. Quarterly updates are available online at Optumcoding.com Product Update / Support page.

Consolidate the coding process with the Coding Companion, your one-stop coding resource developed exclusively for podiatry. This comprehensive and easy-to-use guide is updated for 2023 and organized by specialty-specific CPT® codes. Each CPT® code includes its official description and lay description, coding tip, Medicare edits, and relative value units and is cross-coded to common ICD-10-CM diagnosis codes to complete the coding process. Getting to the code information you need has never been so easy.

Key Features and Benefits

• NEW – Evaluation and Management (E/M) Services Guidelines – E/M codes are used every day in your practice. Now with CPT® E/M Guidelines and our Optum Coding Tips, you have all the information you need to select the correct E/M code for the service provided.

• Quickly find information. All the information you need is provided with the CPT® code, including illustrations, lay descriptions, coding tips, clinical terms, Medicare RVUs and IOM references, and commonly associated ICD-10-CM diagnosis codes.

• Procedure code icons – Quickly identify new, revised, add-on, and telemedicine procedure codes, making your coding process for procedures and E/M services quick and efficient.

• ICD-10-CM code icons – Icons identifying male and female only codes, as well as age-related and laterality diagnosis codes.

• Easily determine fees for your practice and reinforce consistency in the charges. Relative value units including the practice, work, and malpractice components with the total RVUs for nonfacility and facility are included.

• CPT® Assistant references. Identifies that an article or discussion of the CPT® code has been in the American Medical Association’s CPT® Assistant newsletter. Use the citation to locate the correct volume.

• Avoid claim denials and/or audits. Medicare payer information includes references to Internet Only Manual (IOM) guidelines, follow-up days, and assistant-at-surgery.

• CCI edits by CPT® and HCPCS procedure code. CPT® and HCPCS procedure codes with their associated CCI edits are provided in a special section. Quarterly updates are available online at Optumcoding.com Product Update / Support page.