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.

    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.

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.