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Essentials for Clinical Documentation Integrity

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From its MDC-aligned structure to its wealth of valuable detail, this CDI training resource simplifies chart reviews and makes it easier to know when to initiate a physician query.

Non-Member Price: $167.00

Product Code: PCDS


Book Format*:



A faster, easier pathway to high-quality documentation

High-quality clinical documentation plays an essential role in getting paid correctly and improving patient outcomes. Our clinical documentation integrity (CDI) book measures up to this critical function, using a three-step approach that covers possible clinical indicators, risk factors and treatments, enabling effective chart reviews and physician queries. Divided into major diagnostic categories (MDCs), this convenient handbook integrates coding rules and guidelines, DRG assignments, breakdowns of ICD-10 codes and high-risk DRGs. In addition, solidify your knowledge through case studies, anatomy and physiology lessons, at-a-glance reference aids, diagrams and much more. It’s the ideal training tool for both new and seasoned CDI specialists!

Features and Benefits

Clear, step-by-step guidance tailored to busy professionals:

  • Divided into MDCs in DRG layout, for the fastest, easiest navigation of any CDI how-to resource on the market
  • Comprehensive anatomy and physiology lessons in every chapter, topped off with discussions of documentation and coding
  • Coding guidelines and tips, plus AHA coding clinic references and a breakdown of ICD-10 codes into an easy-to-learn format
  • Case studies drawn from actual documentation, with questions and answers — a great tool for testing CDI competency
  • Guidance with implementing a CDI program and measuring its effectiveness
  • Discussion of laboratory values and quality/risk management issues
  • Numerous at-a-glance learning and reference aids, including charts/diagrams for knowing when to initiate physician queries and tracing documentation to the appropriate codes
  • Searchable format (PDF version) for quickly finding answers to questions

Updated and expanded content, including:

  • Clarifies coding issues for COVID diagnosis, ongoing symptoms and recovery
  • Incorporates MS-DRG changes, based on the IPPS final rule, throughout the book; includes OR designation shifts
  • Updated with all new CC/MCCs and CC/MCC shifts
  • Revised and updated information and guidance specific to new ICD-10-CM/PCS codes
  • Details on the new classification of pressure ulcers
  • Guidance with social determinants of health and the ramifications for CDI staff
  • Enhanced comprehensive MS-DRG tables, enabling faster identification of current DRG mix, potential opportunities and the latest changes

*Subscribers to the Interventional Radiology, Radiology, or Comprehensive All-Access Pass, and/or MedLearn Media Resource Center receive 30% off the print version of the books included with their membership. This 30% does not include AMA fees or shipping and handling fees. For questions please email us at support@medlearnmedia.com.

**Please note that eBooks cannot be printed, and all sales on eBooks are final. If you would like a printed copy of this resource please select the Print version and allow time for shipping.