clinical coding reference

nicolebolandnicoleboland
in Clinical & Coding
Can  anyone  suggest  a  good  clinical  coding  reference  for  a  new  CDI  RN ?
Something  that  explains  the  clinical  indicators   needed  to  be  able  to   code  certain  diagnosis.
Thanks  so  much,  Nicole.

Tagged:

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com

    I don't know if you are truly looking for a coding reference or a CDI reference? Coders have to code the dx if it is documented, regardless of clinical indicators. If you are concerned about recognizing clinical indicators in order to query for a dx or to support/validate a diagnosis that is already made you could start with the CDI handbook or pocket guide. Ultimately a medical reference is needed. Our primary reference is UpToDate though we look for support in the major journals and medical books as well.

    Katy




  • morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu

    The CDI Pocket Guide is a great reference to have. Optum also has a book entitled "Guide to Clinical Validation, Documentation, and Coding. Validating code assignments with clinical documentation". I think you can google the title and see a sample of the book or either search www.optumcoding.com and see if you can see a preview of the content. I would recommend the CDI Pocket Guide and the Optum book if you can get both.

    Jeff

  • kelly.harneykelly.harney
    Agree, CDI Pocket Guide by Pinson and Tang is the best clinical indicator reference that I have seen. 
  • kelly.harneykelly.harney

    Hi Nicole,

    I would also recommend an ACDIS Bootcamp, if you have not already attended one

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org

    The CDI Pocket Guide is one of the most concise and complete guides I have used.  Very helpful in many respects.  I also agree the Bootcamp is an excellent resource.


    Paul

  • cindys@hollandhospital.orgcindys@hollandhospital.org
    CDI Pocket Guide by Pinson and Tang
  • jackietouch@aol.comjackietouch@aol.com
    Currently we use the CDI Pocket Guide and UpToDate. Thank you, Jeff, for citing the Optum reference: Looks like a valuable addition to our references and I have pre-ordered a copy.

    Jackie
  • norrmall@earthlink.netnorrmall@earthlink.net
    Clinotes, a book of clinical indicators was beneficial as a new CDS. It is filled with diagnoses and their s/s that may also help you out.  Good luck!
  • morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu
    norrmall said:
    Clinotes, a book of clinical indicators was beneficial as a new CDS. It is filled with diagnoses and their s/s that may also help you out.  Good luck!


    Do you know who publishes this? It sounds like a great resource!

    Jeff

  • guerriguerri
    jwmorris1 said:
    norrmall said:
    Clinotes, a book of clinical indicators was beneficial as a new CDS. It is filled with diagnoses and their s/s that may also help you out.  Good luck!


    Do you know who publishes this? It sounds like a great resource!

    Jeff


    Channel Publishing. It's really a great resource.

    I would also study/learn new and old Coding Clinics, the Official Coding Guidelines. They aren't clinical resources, however they are just as important, IMO.


    -Richard

Sign In or Register to comment.