Synopsis:
Clinical documentation improvement (CDI) is not about how to code in ICD-10-CM or CPTr; CDI is knowing what to look for in medical records, as well as how to ask for clarification and get ongoing changes to the notes and comments provided by physicians. Important Note: The greater number of ICD-10-CM diagnostic codes means an even bigger need for detailed clinical documentation. Making the right code selection requires having adequate clinical detail and, under ICD-10-CM, clinician's documentation will more than ever translate into reimbursement gained or lost.
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