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

Optum | 2025 | Leanne Patterson; Laura Anderson

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.

  • NEW – Expansion of medical diagnosis topics. New medical conditions added with the clinical criteria and documentation requirements that support ICD-10-CM code assignment.
  • 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

Leanne Patterson, CPC

Ms. Patterson has more than 15 years of experience in the healthcare profession. She has an extensive background in professional component coding, with proven expertise in assignment of E/M codes, general surgery coding, medical record documentation improvement, and HIPAA compliance. Her experience includes serving as Director of Compliance, conducting chart-to-claim audits, and physician education. She has been responsible for coding and denial management in large multi-specialty physician practices, and most recently has been part of a team developing content for products related to ICD-10-CM. Ms. Patterson is credentialed by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC).

Laura Anderson, RN, BSN, CCDS

Ms. Anderson is a Registered Nurse and CDI Specialist/Educator with more than 20 years of experience in the healthcare profession. She obtained her BSN at the University of Minnesota and spent most of her bedside nursing career on Medical-Surgical care units. Her clinical documentation experience began in 2007, covering CDI specialist training, education development, and physician engagement. She has served as a CDI Team Lead and consultant, working with senior leadership to incorporate CDI work into documentation compliance and quality metrics. Ms. Anderson also has a BS degree in Biology (Winthrop University), with research experience in liver cancer and radiation-induced leukemia. She has presented at the state and national levels for the Association of Clinical Documentation Integrity Specialists (ACDIS) and has served as a co-lead for the Minnesota state chapter.