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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 E/M leveling with comprehensive 2023 guideline updates

IMPORTANT NOTE: If you already have the first or second edition of the Clinical Documentation Reference Guide, you will want to upgrade to the third edition, which includes updates for the E/M code and guidelines changes that occurred in 2023. This new edition removes deleted CPT® codes and replaces official descriptors for all revised CPT® codes. The updates include tips for what information to capture under the new E/M guidelines plus new resources for simplifying documentation and querying providers.


ISBN 9781646319985
SKU A24BUN0043
Publication Date 7/1/2023
Language of Text English
Binding Spiral-bound
Format Softcover
Publisher AAPC
Country/Region of Origin USA


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