American Medical Association 
ICD-10-CM Documentation 2021: Essential Charting Guidance to Support Medical Necessity 

ICD-10-CM requires very specific documentation to correctly choose diagnostic codes, a skill that both coders and physicians must master to code successfully. Moving beyond the transition to ICD-10, the new edition focuses on the key role proper documentation plays in supporting medical necessity. ICD-10-CM Documentation 2021 brings coders and physicians together to ensure documentation success, identifying all ICD-10-CM documentation requirements using detailed checklists. Designed for use alongside an ICD-10-CM codebook, this comprehensive training guide provides all the tools necessary to conduct an effective documentation analysis and to create a corrective action plan, making it ideal for both non-facility and facility coders. The chapter organization mirrors the structure of codebooks and all guidance is geared toward the process of code decision-making. In addition, exercises and quizzes test knowledge and understanding of key points throughout the book. FEATURES AND BENEFITSNew codes, revisions and deletions, plus guideline updates for 2021 final changes will be integrated into every pertinent chapter, checklist, scenario and quiz Detailed, full-page anatomy illustrations for better interpretation of clinical notes Checklists to identify documentation elements for categories, subcategories and codes Checklists for specialty-specific documentation to review current records and identify any documentation deficiencies ICD-10-CM documentation scenarios display documentation requirements with important elements highlighted CDI checklists identify common documentation deficiencies faced when coding COPD, Pneumonia and Sepsis/SIRSGlossary of Medical Terminology Scenarios illustrate required documentation in ICD-10-CM with additional ICD-10 requirements highlighted so readers can understand where the documentation will appear in common coding scenarios based on real-life health care encounters End of chapter quizzes dive into coding practice with the conditions discussed in each chapter