Tip: Base code on patient’s initial symptoms for undetermined diagnosis
APCs Weekly Monitor, June 12, 2009
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Physician documentation should describe the patient’s condition, using terminology that includes specific diagnoses as well as symptoms, problems, or reasons related to the encounter.
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Coders may report chronic diseases treated on an ongoing basis as often as the patient receives treatment and care for the conditions.
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Code all documented conditions that coexist at the time of the encounter and that require or affect patient care, treatment, or management.
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