ICD-10 Documentation Strategies to Support Severity of Illness
Ensure an Accurate Professional Profile, Third Edition
Robert S. Gold, MD
Sold in packages of 25 copies!
Written by well-known physician educator Robert S. Gold, MD, this handbook explains the specific documentation details physicians need to express severity of illness and complexity of decision-making for 34 of the most troubling conditions in documentation today.
It explains specific diagnosis-related issues, relieving physicians of much of the rework associated with utilization review, case management, and HIM/medical records concerns.
The third edition has been updated to help physicians understand the documentation rules for ICD-10.
Table of Contents:
Chapter 1: Acute Myocardial Infarction
Chapter 2: Adverse Effects of Medications
Chapter 3: Alcohol and Substance Use and Abuse
Chapter 4: Anemia
Chapter 5: Atrial Arrhythmias: Fibrillation, Flutter
Chapter 6: Chest Pain and Angina
Chapter 7: Chronic Obstructive Pulmonary Disease
Chapter 8: Comfort Measures Only
Chapter 9: Comorbidities or Comorbid Conditions
Chapter 10: Complications: Postoperative
Chapter 11: Cor Pulmonale: Acute Due to Massive Pulmonary Embolism
Chapter 12: Coronary Artery Disease Debridement
Chapter 13: Dementia, Delirium, and Encephalopathy
Chapter 14: Fractures
Chapter 15: Gastrointestinal Bleed
Chapter 16: Heart Failure
Chapter 17: Hyperglycemia Hypertension
Chapter 18: Inflammatory Bowel Disease
Chapter 19: Low Anterior Resection Malignancies
Chapter 20: Malnutrition
Chapter 21: Obesity
Chapter 22: Peripheral Vascular Disease
Chapter 23: Pneumonia
Chapter 24: Pulmonary Edema Renal Failure
Chapter 25: Respiratory Failure Seizures
Chapter 26: Sepsis
Chapter 27: Stroke or Cerebrovascular Chapter 28: Accident
Chapter 28: Symptoms
Chapter 29: Syncope
Chapter 30: Trauma
This handbook explains the specific documentation details physicians will need to express severity of illness and complexity of decision-making under ICD-10.
About the Author:
Robert S. Gold, MD, is known nationally for his presentations regarding the clinical orientation of coding in AHIMA and HCPro audio conferences. He has spoken at national and state-level Healthcare Financial Management Association and Healthcare Compliance Association meetings about the participation of the medical staff in documentation improvement programs. He writes the monthly columns “Clinically Speaking” for Briefings on Coding Compliance Strategies and “Minute for the Medical Staff” for Medical Records Briefing. Dr. Gold also is a cofounder of DCBA, Inc., a consulting company that provides physician-led programs in clinical documentation improvement (CDI), with training of CDI specialists and with coder education in the diagnoses and procedures to which they assign codes.
Published: December 2013