ICD-10 Documentation Quick Reference Guide

ICD-10 Documentation Quick Reference Guide



The ICD-10 Documentation Quick Reference Guide, available as a downloadable .pdf, is a helpful tool for clinicians and CDI specialists who want to ensure their documentation provides sufficient detail to allow complete and accurate coding. Includes detailed instructions for documentation of both diagnoses and procedures in 17 individual specialties. Purchase one or the complete set.

CEUs:     N/A - AHIMA      N/A - AAPC

Rather than a checklist of likely codes, Libman Education’s ICD-10 Documentation Quick Reference Guide provides detailed and succinct guidance on what to document in an easy to use downloadable .pdf. Ensure your documentation is complete:

  • Laterality (left, right, bilateral, multiple locations)
  • Detailed locations (Head, Shaft, Proximal, Distal, individual body part, etc.)
  • Episode of care (Initial, Subsequent, Sequela)
  • Status of disease (Acute, Chronic, Intermittent, Recurrent, Transient, Primary versus Secondary)
  • Root Operations most likely to be used in the specialty and the documentation required for your hospital to accurately assign them
  • Intent, exact location, and types of devices left in place
  • And more!

The ICD-10 Documentation Quick Reference Guide for each specialty provides detailed guidance, condensed into 3-4 pages. Organized by specialty, both medical and surgical, the ICD-10 Documentation Quick Reference Guide can be purchased individually or as a complete 17-specialty set:

  • Cardiovascular
  • Dermatology
  • Endocrinology (ICD-10-CM only)
  • ENT
  • Gastroenterology
  • General Surgery
  • Hematology – Oncology
  • Internal Medicine and Family Practice
  • Mental Health and Substance Abuse
  • Nephrology – Urology
  • Neurology and Neurosurgery
  • Obstetrics and Gynecology
  • Ophthalmology
  • Orthopedics
  • Pediatrics
  • Pulmonology
  • Rheumatology

Note:  While the ICD-10 Documentation Quick Reference Guide is not a coding tool and contains no code numbers, using the guide will ensure your documentation provides sufficient detail to allow complete and accurate coding.


Lynn Kuehn is president of Kuehn Consulting, LLC, in Waukesha, Wisconsin, a consulting firm specializing in coding for all settings and physician practice management issues. Lynn is a nationally recognized trainer on ICD-10-PCS and other HIM-related topics.

Lynn served on the AHIMA Board of Directors and authored several of AHIMA’s most popular books including Procedural Coding and Reimbursement for Physician ServicesCCS-P Exam Preparation, and ICD-10-PCS: An Applied Approach.

Together with her co-Author Theresa Jorwic, Lynn received the Triumph Literary Legacy Award from AHIMA for ICD-10-PCS: An Applied Approach. This book has been named the “go-to” resource for learning and mastering ICD-10-PCS.  ICD-10-PCS: An Applied Approach provides step-by-step instructions and exercises at all levels, and is used throughout Kuehn’s ICD-10-PCS courses authored for Libman Education.


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