Clinical Documentation Sourcebook

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Do you need help ensuring your documentation is accurate, timely, and reflects the scope of services provided? Look no further.

The Clinical Documentation Sourcebook unravels the biggest challenges for clinical documentation improvement (CDI) in ICD-10 and gives you the inside scoop on CDI for EMRs, as well as E/M, hospice, home health, and more.

We cover preventative care visits, the global surgical package, joint/shared visits, incident-to billing, and our ICD-10 CDI toolkit, along with TCI expert advice and clear, and practical guidance to frequently asked CDI questions that will transform your productivity—and your profits.

Improve your clinical documentation across the board and say goodbye to underpayments and audits:

  • Understand the legal aspects of documentation
  • Anticipate documentation problems and learn how to avoid them
  • Learn the coding mantra—specificity, specificity, specificity
  • Avoid these common documentation errors identified by CERT/RAC
  • Know the facts about EMR templates—and issues with the auto-populate feature in EMRs
  • Don’t overlook these costly EMR errors
  • Nail down documentation in the EMR — guidelines and tips
  • Keep compliance issues at bay with these pointers
  • Heed caution with the biggest challenges for CDI in ICD-10
  • Benefit from trauma, infection, and medical conditions documentation pointers
  • Profit with tips to select the correct diagnosis code from the superbill
  • Capitalize on auditing advice for ICD-10 and CDI
  • Take stock of common deficiencies in home care documentation
  • Grasp Medicare eligibility criteria for home care
  • Get clarification on documentation for E/M coding
  • Master CDI time-based coding for E/M
  • Get the skinny on coding the initial preventative physical examination for Medicare

PLUS—Hone your clinical documentation expertise:

  • Coding exercise and examples
  • Actual documentation scenarios
  • ICD-10 CDI Toolkit
  • TCI expert advice
  • Expert answers to frequently asked CDI questions
  • 1995 and 1997 documentation guidelines for E/M

And so much more!

ORDER ONLINE or call 1-800-508-2582 today to get your copy of the Clinical Documentation Sourcebook.

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