Documentation Improvement Handbook 10-19-11 PROOF.PDF

Specificity: Coding rules require precise documentation as to location, laterality, device, approach, procedure, qualifier; eg., meningitis due to Lyme Disease, malignant neoplasm of lower quadrant of right female breast, atherosclerotic heart disease of native coronary artery with unstable angina pectoris Consistency: Diagnoses are noted and then repeated throughout the patient’s stay. ................
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