ICD-10 Clinical Documentation Improvement Document

For those of you tasked with training and/or coding in ICD-10, there's an excellent resource on the American Health Information Management Association (AHIMA) website.  It's a 72 page document on clinical documentation improvement for ICD-10.  In other words, it's a guide to helping both coders and clinicians understand the documentation requirements for a number of ICD-10 codes.

While encoders and crosswalks may be able to point you in the right direction, all coding is done based on the documentation in the medical record.  This guide can help you understand the documentation requirements for a number of diagnoses and services.

The document is accessible to both AHIMA members and non-members in their body of knowledge, and can be downloaed here.