How You Can Help – What To Code
How You Can Help – What To Code
Complete Diagnostic Coding, not just primary Diagnosis
• Providers must report all diagnoses that impact the patient’s evaluation, care, and treatment including:
o Main reason for visit
o Co-existing acute conditions
o Chronic conditions (such as Atrial fibrillation, CHF, Chronic Renal Failure, Rheumatoid arthritis, Crohn’s disease, Diabetes, COPD/ Asthma, & Cardiomyopathy)
1 Pertinent past conditions
Documentation Retains Reimbursement: The listing of Diagnosis codes is not enough, there must be evaluation. The Medical Record must thoroughly document all conditions evaluated: Evaluative documentation would include statements such as: Stable on Meds, condition worsening –medication adjusted, tests ordered – documentation reviewed, condition improving.
Superbills and Documentation: Checking a box to designate an ICD-9 code on the Superbill does not document the conditions assessed. It must be in the chart notes. Superbills are not a documentation source.
References
•Web Based Training available via CMS Web Site
–
–Go to: Providers
–Click on: Physicians
–Search Box: coding
–Click on: ICD9 CM Diagnosis Coding
–Click on: Web Based Training (WBT) for ICD-9 Coding
–Click on: Web/Computer-Based Courses
•Free ICD9 DX Coding web site:
•Superbills – ICE Library sample super bill
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ICD-9-CM 2006 – The Source of Current Codes and Guidelines
Go to nchs/data/icd9/icdguide.pdf for 71 pages of Official Guidelines from CMS
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