Documentation & Coding Archives

Code ICD-10 Diagnosis with Confidence

Tips for Coding ICD-10 Diagnosis If you are responsible for reading documentation and finding the correct ICD-10 code, are you always confident that you have selected the correct code? If the answer is no, you are not alone. Here are some tips that we have found useful: Know the rules- Make sure you have read…

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Written Diagnosis Vs ICD-10 Coding in Documentation

DX 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 of…

Documentation or Diagnosis – Which came first?

The clinical diagnosis process should be second nature to every provider. But what does that mean? The expectation is that each time you diagnose a patient, you move through the process of gathering information to assess and arrive at the diagnosis that most accurately describes the patient’s condition. The process should be easily tracked in…

The Clinical Diagnosis Process

The Diagnosis is Not an Assessment Chiropractors often confuse a diagnosis with the assessment portion of an initial visit note. The diagnosis and the treatment plan are just components of the assessment. The assessment, coupled with the information gathered while taking the patient’s history during examination, and his/her working diagnosis, reveals more about the patient…

Documentation Drives Coding

Far too often, we find a fancy code (maybe a new code) and want to find a way to charge for it. This is completely backward. Documentation must drive coding. This simple visual reminder outlines the process of starting with the documentation and coding from there. Utilize this concept to re-enforce the dependency that each…

Basic Documentation and Coding Guidelines

Guidelines, guidelines everywhere, and not a clear understanding to be found. As you learn about the ins and outs of documentation and diagnosis coding, you must be aware of where the requirements come from. There are continual changes in the guidelines and as a provider you need to know who is making the rules to…