2025 Clinical Documentation Improvement Desk Reference for ICD-10-CM and Procedure Coding

Optum | 2025 | Elizabeth Leibold



139.95
List Price

Item #: CDI25
ISBN: 9781622549719
Available: Dec 31 2024








Clinical documentation improvement (CDI) is not about how to code in ICD-10-CM or CPT®. CDI is about knowing what to look for in medical records and 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 correct 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.





  • Optum Edge — HCC and QPP icon alerts added at the code level to aid in coding. 
  • Optum Edge — A list of medications is noted for codes that are deemed applicable. 
  • Optum Edge — The “Clinician’s Checklist for ICD-10-CM.” Make copies of this handy trifold, pocketsize card for every clinician. Provides powerful documentation tips for the 5 most important chronic and acute conditions. 
  • Diagnoses and Procedures — Covers documentation for CPT®, HCPCS, and ICD-10-CM coding. Enhance your code selections with documentation requirements for all three coding systems. 
  • Physician Documentation Training. Show physicians what they need to document. Documentation training includes 21 detailed documentation checklists for the most common and complex medical conditions. 
  • Don’t teach your clinicians to code ICD-10-CM. Instead show them what you need for optimal code assignment. 
  • See key terms. Confirm accurate code selection for every chapter of ICD-10-CM. 
  • Terminology Translator. This unique feature is included at the code level.
  • Streamline the query process. Show physicians which medical terms are essential to assigning codes in ICD-10-CM. Includes best practice query forms that get results without unduly influencing clinicians. 

CPT® is a registered trademark of the American Medical Association


Elizabeth Leibold, RHIT

Ms. Leibold has more than 25 years of experience in the healthcare profession. She has served in a variety of roles, ranging from patient registration to billing and collections, and has an extensive background in both physician and hospital outpatient coding and compliance. She has worked for large health care systems and health information management services companies, and has wide-ranging experience in facility and professional component coding, along with CPT® expertise in interventional procedures, infusion services, emergency department, observation, and ambulatory surgery coding. Her areas of expertise include chart-to-claim coding audits and providing staff education to both tenured and new coding staff. She is an active member of the American Health Information Management Association (AHIMA).

CPT is a registered trademark of the American Medical Association.


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