Health Information Management

To code or not to code: That is the question

Briefings on Coding Compliance Strategies, February 1, 2008

ICD-9-CM diagnostic and procedural code assignment usually follows certain patterns. But despite this familiarity, assigning diagnostic codes is sometimes muddy at best. For example, a patient presents to the hospital with a set of signs or symptoms that may represent several different disease processes. The admitting physician usually documents one of the following three items: Abnormal lab findings, symptoms, or physical findings A list of differential diagnostic considerations "Rule out (R/O)"

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