2020 ACDIS Pocket Guide

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2020 ACDIS Pocket Guide

Product Code: CDIPG20--

2020 ACDIS Pocket Guide

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2020 ACDIS Pocket Guide: The essential CDI resource

The new 2020 ACDIS Pocket Guide is your essential CDI resource. It includes updates to clinical diagnostic standards, the Official Coding Guidelines, ICD-10-CM codes, CMS-HCCs and CDI critical thinking tips! The 2020 ACDIS Pocket Guide is co-written by ACDIS’ CDI Education Director Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, and a practicing physician steeped in the latest physician documentation terminology, James Manz, MD, CCDS-O.

Be sure to include the #1 CDI resource in your library today!

Bonus: With every purchase of the 2020 ACDIS Pocket Guide, you’ll also receive access to the content in digital format (Adobe Digital Editions eBook), which will allow you to easily access all content downloaded to your desktop PC or laptop.

The 2020 ACDIS Pocket Guide is divided into six sections – regulatory/coding guidance, IPPS reimbursement updates, including DRG and CC/MCC updates, compliant query best practices and standards, clinical validation and diagnostic definitions, and comorbidity and MS-DRG lists. The majority of the pocket guide is dedicated to clinical validation and diagnostic definitions, which includes an expansive listing of diagnoses significant to CDI practice.

Conditions covered in the Pocket Guide are organized by their Major Diagnostic Category (MDC), and then in alphabetical order. Each diagnosis listed is accompanied by a detailed clinical definition of the condition, clinical indicators that support the presenting condition, including diagnostic criteria and treatment protocols, ICD-10-CM chapter-specific documentation requirements, including the latest coding clinic guidance specific to the condition, CDI critical thinking tips and provider focused education advice related to the diagnoses.

Below is an example of the diseases and disorders captured in the MDC 4: Diseases and Disorders of the Respiratory System chapter:

  • Acute Respiratory Distress Syndrome
  • Asthma
    • Asthma exacerbation
    • Acute severe asthma (status asthmaticus)
  • Bronchitis/COPD
  • Bronchoscopy, Lung Biopsy
    • Bronchial or endobronchial biopsy
    • Transbronchial biopsy
    • Transbronchial needle aspiration (TBNA)
    • Bronchoalveolar lavage (BAL)
  • Mechanical Ventilation
  • Pneumonia
    • Pneumonitis
    • Community Acquired Pneumonia (CAP)
    • Healthcare Associated Pneumonia (HCAP)
    • Hospital Acquired Pneumonia (HAP)
    • Ventilator Associated Pneumonia (VAP)
    • Pleural Effusion
    • Empyema
  • Pneumothorax, including six categories (primary spontaneous, secondary spontaneous, traumatic, hemopneumothorax, iatrogenic, tension)
  • Respiratory Failure (acute and chronic)
  • Post-Procedural Respiratory Failure


Check out a free chapter preview here!


Published: November 2019

Page count: 482
ISBN: 978-1-68308-979-7

Table of Contents

Table of Contents PDF here!

Introduction

Official Coding Guidance

  • Guidelines Organization
  • ICD-10-CM Coding Conventions
  • General Coding Guidelines
  • Selection of the Principal Diagnosis
  • Reporting Additional Diagnoses
  • Present on Admission Reporting Guidelines
  • Code Assignment for Special Patient Populations

Inpatient Prospective Payment System (IPPS) Reimbursement

  • Common Definitions
  • Determining the MS-DRG
  • Secondary Diagnoses That Impact DRG Assignment: Complications and Comorbidities
  • MS-DRGs vs. APR-DRGs
  • Risk Adjustment Methodologies
  • Value-Based Payment

Compliant Query Practice

  • Notes on Querying and Clinical Validation
  • Why Do We Query?
  • The Role of Clinical Indicators in Queries
  • Three Types of Query Formats
  • Compliant Verbal Queries
  • Use of Query Templates
  • Maintaining Compliant Practice
  • The Process of Clinical Validation

MDC 1: Diseases and Disorders of the Nervous System

  • Cerebral Edema (G93.6)/Brain Compression (G93.5)
  • Cerebral Palsy (G80.-)
  • Cerebrovascular Accident (I61.-, I62.-, and I63.-)
  • Transient Ischemic Attack (G45.9)
  • Coma (R40.2-)/Persistent Vegetative State (R40.3)
  • Encephalopathy

MDC 4: Diseases and Disorders of the Respiratory System

  • Acute Respiratory Distress Syndrome
  • Asthma
  • Bronchitis/COPD
  • Mechanical Ventilation
  • Pneumonia
  • Pneumothorax
  • Respiratory Failure
  • Post-Procedural Respiratory Failure
  • Bronchoscopy/Lung Biopsy
  • E-Cigarette, or Vaping, Product Use Associated Lung Injury (EVALI)/Vaping-Associated Pulmonary Injury (VAPI)

MDC 5: Diseases and Disorders of the Circulatory System

  • Atrial Fibrillation
  • Cardiac Arrest
  • Heart Failure
  • Hypertensive Crisis
  • Myocardial Ischemia
  • Pulmonary Hypertension
  • Shock

MDC 6: Diseases and Disorders of the Digestive System

  • Clostridium Difficile Colitis
  • Gastrointestinal Bleed
  • Intestinal Obstruction (Ileus)

MDC 7: Diseases and Disorders of the Hepatobiliary System and Pancreas

  • Acute Liver (Hepatic) Failure
  • Pancreatitis

MDC 8: Musculoskeletal System and Connective Tissue

  • Pathological Fractures
  • Rhabdomyolysis

MDC 9: Skin, Subcutaneous Tissue, and Breast

  • Chronic Skin Ulcers
  • Debridement Procedures

MDC 10: Endocrine, Nutritional, & Metabolic Diseases and Disorders

  • Acid-Base Disorders
  • Body Mass Index (BMI)
  • Cystic Fibrosis
  • Diabetes Mellitus
  • Electrolyte Disorders
  • Malnutrition
  • Morbid Obesity

MDC 11: Diseases and Disorders of the Kidney and Urinary Tract

  • Acute Kidney Injury (AKI)/Acute Renal Failure (ARF)
  • Acute Tubular Necrosis (ATN)
  • Chronic Kidney Disease (CKD)

MDC 16: Blood and Blood-Forming Organs

  • Anemia
  • Coagulation Disorders
  • Neutropenia
  • Pancytopenia

MDC 17: Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms

  • Neoplasms

MDC 18: Infectious and Parasitic Diseases

  • Sepsis
  • Systemic Inflammatory Response Syndrome (SIRS)
  • Resistance to Antimicrobial Drugs

MDC 19: Mental Diseases and Disorders

  • Delirium
  • Major Depressive Disorder
  • Intellectual Disabilities

MDC 20: Alcohol/Drug Use & Alcohol/Drug Induced Organic Mental Disorders

  • Alcohol and Drugs
  • Nicotine Dependence

MDC 21: Injuries, Poisonings, and Toxic Effects of Drugs

  • Fractures
  • Organ Injuries
  • Poisonings/Adverse Reactions/Toxic Effects/Underdosing

MDC 22: Burns and Corrosions

  • Burns and Corrosions

MDC 25: Human Immunodeficiency Virus Infections

  • HIV Disease

Pediatric and Neonatal Population

  • Vital Signs for Pediatric Patients
  • Glasgow Coma Scale (pGCS)
  • Malnutrition
  • Pediatric BMI
  • Physeal Fractures
  • Respiratory Conditions (Neonatal)
  • Respiratory Failure (Pediatric)
  • Sepsis (Neonatal/Pediatric)

Social Determinants of Health

Comorbidity List

MS-DRG Table


Alphabetic List of Conditions

Acid-Base Disorders
Acute Kidney Injury (AKI)/Acute Renal Failure (ARF)
Acute Liver (Hepatic) Failure
Acute Respiratory Distress Syndrome
Acute Tubular Necrosis (ATN)
Alcohol and Drugs
Anemia
Asthma
Atrial Fibrillation
Body Mass Index (BMI)
Bronchitis/COPD
Bronchoscopy/Lung Biopsy
Burns and Corrosions
Cardiac Arrest
Cerebral Edema (G93.6)/Brain Compression (G93.5)
Cerebral Palsy (G80.-)
Cerebrovascular Accident (I61.-, I62.-, and I63.-)
Chronic Kidney Disease (CKD)
Chronic Skin Ulcers
Clostridium Difficile Colitis
Coagulation Disorders
Coma (R40.2-)/Persistent Vegetative State (R40.3)
Cystic Fibrosis
Debridement Procedures
Delirium
Diabetes Mellitus
E-Cigarette, or Vaping, Product Use Associated Lung Injury (EVALI)/Vaping-Associated Pulmonary Injury (VAPI)
Electrolyte Disorders
Encephalopathy
Fractures
Gastrointestinal Bleed
Glasgow Coma Scale (pGCS)
Heart Failure
HIV Disease
Hypertensive Crisis
Intellectual Disabilities
Intestinal Obstruction (Ileus)
Major Depressive Disorder
Malnutrition
Malnutrition (Pediatric)
Mechanical Ventilation
Morbid Obesity
Myocardial Ischemia
Neoplasms
Neutropenia
Nicotine Dependence
Organ Injuries
Pancreatitis
Pancytopenia
Pathological Fractures
Pediatric BMI
Physeal Fractures
Pneumonia
Pneumothorax
Poisonings/Adverse Reactions/Toxic Effects/Underdosing
Post-Procedural Respiratory Failure
Pulmonary Hypertension
Resistance to Antimicrobial Drugs
Respiratory Conditions (Neonatal)
Respiratory Failure
Respiratory Failure (Pediatric)
Rhabdomyolysis
Sepsis
Sepsis (Neonatal/Pediatric)
Shock
Social Determinants of Health
Systemic Inflammatory Response Syndrome (SIRS)
Transient Ischemic Attack (G45.9)
Vital Signs for Pediatric Patients

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Add Association of Clinical Documentation Integrity Specialists (ACDIS)

$20 discount on your one-year ACDIS Membership will be applied at check out.

ACDIS is a community of CDI professionals who share the latest tips, tools, and strategies to implement successful CDI programs and achieve professional growth.

ACDIS members receive: 

  • Advocacy and leadership from a peer-elected ACDIS Advisory Board, including peer-reviewed Position Papers and White Papers.
  • Weekly tips, news, and strategies in our e-newsletter, CDI Strategies
  • In-depth news and regulatory information, clinically-based articles, case studies on building successful CDI programs, and membership profiles in our bi-monthly electronic journal, the CDI Journal
  • An opportunity to network with peers and colleagues in the ACDIS Forum
  • Access to live and archived quarterly conference calls, hour-long networking discussions and an open Q&A with the ACDIS Advisory Board
  • Helpful tools accessed in our electronic Resource Library, including sample queries, policies, and archived conference presentations
  • Two free job postings a year, discounted additional posts, and the ability to post your resume on our Career Center
  • Opportunities to participate in an Official ACDIS Local Chapter in your area, under the leadership of the Chapter Advisory Board
  • Discounts to the annual ACDIS conference, CCDS certification, and CDI Boot Camps


To explore all that ACDIS has to offer, please
visit the ACDIS Web site.