It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.

Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.

All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.

The Clinical Documentation Improvement Specialist's Handbook, Second Edition Marion Kruse, MBA, RN; Heather Taillon, RHIA, CCDS Get the guidance you need to make your CDI program the best there is... The Clinical Documentation Improvement Specialist's Handbook, Second Edition, is an all-inclusive reference to help readers implement a comprehensive clinical documentation improvement (CDI) program with in-depth information on all the essential responsibilities of the CDI specialist. This edition helps CDI professionals incorporate the latest industry guidance and professional best practices to enhance their programs. Co-authors Heather Taillon, RHIA, and Marion Kruse, MBA, RN, combine their CDI and coding expertise to explain the intricacies of CDI program development and outline the structure of a comprehensive, multi-disciplinary program. In this edition you will learn how to: Adhere to the latest government and regulatory initiatives as they relate to documentation integrity Prepare for successful ICD-10 transition by analyzing your CDI program Step up physician buy-in with the improved education techniques Incorporate the latest physician query guidance from the American Health Information Management Association (AHIMA) Table of Contents Chapter 1: Building the CDI Program Chapter 2: CDI and the healthcare system Chapter 3: Application of coding guidelines Chapter 4: Compliant physician queries Chapter 5: Providing physician education Chapter 6: Monitoring the CDI program What's new in the Second Edition? Analysis of new industry guidance, including: AHIMA's "Managing an Effective Query Process" and "Guidance for Clinical Documentation Improvement Programs." CMS guidance from new IPPS regulations, MLN Matters articles, Quality Improvement Organizations, and the Recovery Audit Contractor (RAC) program, among others Strategies to help you incorporate the guidance into your CDI program. Tools to help you interpret MAC initiatives and RAC focus areas to enhance your CDI program and help prevent audit takebacks New sample queries, forms, tools, and industry survey data BONUS TOOLS! This book also includes bonus online tools you can put to use immediately! Sample query forms Sample job descriptions for CDI managers, and CDI specialists Sample evaluation form for CDI staff Sample pocket guide of common documentation standards

Defeat the challenges that threaten your E/M claims and compliance success. Evaluation and management (E/M) services are the lifeblood of your revenue stream, and yet they’re the most problematic to report. Claim denials remain high. E/M coding errors, in fact, rose from 11.9% in 2018 to account for 12.8% of CMS’s overall 2019 improper payment rate. How much E/M revenue are you losing? Safeguard your organization from claim denials and audit scrutiny with the Evaluation & Management Coding Reference Guide. Our experts break down E/M coding rules and requirements into simple, manageable steps written in everyday language to boost your E/M reporting skills. Learn how to capture the key components of medical history, physical exam, and medical decision-making—and capitalize on real-world clinical scenarios to prevent over- or under-coding. The Evaluation & Management Coding Reference Guide will help you prep for 2021 E/M guideline changes overhauling new and established office and outpatient services, and walk you through online digital E/M services, remote physiologic monitoring, and more. Master the ins and outs of E/M coding—CPT® guidelines, level of service, modifiers, regulations, and documentation guidelines. Put an end to avoidable denials and optimize your E/M claims for full and prompt reimbursement. Benefit from expert tutorials covering the spectrum of E/M reporting concepts and challenges: Prep for 2021 guideline changes and their impact on your organization Master the ins and outs of E/M guidelines in CPT® Capture the seven components of E/M services Sort out medical decision-making coding Avoid the pitfalls of time-based coding Nail down specifics for critical care E/M services Clear up modifier confusion Understand NPPs rules for same-day E/M services Take the guesswork out of complexity determinations Get the details on coding surgery and E/M together Learn the principles of E/M documentation

Recoup lost time and revenue with denials management and appeals know-how. Claim denials can sink a profit margin. And given the cost of appeals, roughly $118 per claim, not all denials can be reworked. A practice submitting 50 claims a day at an average reimbursement rate of $200 per claim should bring in $10,000 in daily revenue. But if 10% of those claims are denied, and the practice can only appeal one, they lose $800 per day—upwards of $200K annually. Your medical claims are the lifeblood of operations. Don’t compromise your financial health. Learn how to preempt denials with the Denials Management & Appeals Reference Guide. This vital resource will equip you to get ahead of payers by simplifying the leading causes of denials and showing you how to address insufficient documentation, failing to establish medical necessity, coding and billing errors, coverage stipulations, and untimely filing. Rely on AAPC to walk you through the appeal process. We’ll help you establish protocols to avoid an appeals backlog and teach you how to identify and prioritize denials likely to win an appeal. What’s more, you’ll learn when a claim can be “reopened” to fix a problem. Collect the revenue your practice deserves with effective denials and appeals solutions: Know how to analyze your denials Defeat documentation and compliance issues for successful claims success Utilize payer policy for coverage clues Lock in revenue with face-to-face reimbursement guidance Refine efforts to avoid E/M claim denials Ace ICD-10 coding for optimum reimbursement Put an end to modifier confusion Stave off denials with CCI edits advice Navigate the appeals process like a pro And much more!