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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.