Written Diagnosis Versus ICD-10 Coding in Documentation
Written Diagnosis vs ICD-10 Coding In the typical Evaluation and Management (E/M) service, providers document the patient’s history, quantify that history with an examination, and from those cornerstones, derive the assessment, diagnosis, and treatment plan. This is recorded in the patient’s health record and using this information, both Current Procedural Terminology (CPT®) and International Classification…