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A Comprehensive Diagnostic Profile - The Wave of the Future
- Good coding and documentation clearly depicts the level of disease severity, co-morbidities and underlying diseases
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According to 2008 ICD9 outpatient coding guidelines "Code all documented conditions that coexist at the same time of the visit and require or affect patient care treatment or management"
3 Common Errors: Documentation & Coding in Physician Office
- Documenting and coding uncomplicated diabetes (250.00) when the patient actually has complicated diabetes
- If urine test indicates protein due to diabetic nephropathy, nephropathy should be documented as:
- 250.40 Diabetes with nephropathy and
- 583.81 Nephropathy due to diabetes
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Documenting and coding cancer when the correct documentation should br "history of cancer"
- If cancer was removed, the patient does not have metastases and is not on active treatment, the coding should be history of (breast, prostate or colon) cancer. V10.x
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Diagnosis of stroke or CVA (434.91 or 436) should only be used in a hospital setting
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If the patient is seen after hospitalization:
- Document the residual effects if present (i.e.: aphasia, hemiplegia), otherwise
document and code status post CVA with no residual. V12.54
Last updated:
1/13/2011 12:00:00 AM
Copyright Aultman Health Foundation
AultCare Information Systems
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