To ensure a neoplasm is coded to the highest level of specificity, documentation should be clear and conscience.
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Tag: #Coding
Coding Corner: Vascular Disease Documentation & Coding
When documenting and coding a patient’s vascular disease, specify the underlying cause, artery, and location.
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Coding Corner: Substance Use Disorder Documentation & Coding
When documenting and coding substance use disorder (SUD), specify the severity by using ICD-10 codes.
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Quality Measures: Consistent Versus Contradictory Documentation
The accuracy and specificity of documenting one’s medical conditions, as well as the internal consistency within a note, are of paramount importance.
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Download: Social Determinants of Health ICD-10 Codes One Sheet
As part of the 2021 changes in the Evaluation & Management coding system, the American Medical Association has, for the first time ever, included Social Determinants of Health in the calculus for Medical Decision Making (MDM).
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ICD-10 Coding: Documentation & Coding of Social Determinants of Health
The medical record determined by ICD-10 Coding tells a story. It is composed of a narrative of what is happening with a patient. It includes objective physical exam findings, which correlate to signs, symptoms, assessed medical conditions; a detailed plan…
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