Health Information Management

Tip: Base code on patient’s initial symptoms for undetermined diagnosis

APCs Insider, June 12, 2009

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

When a physician is unable to determine a diagnosis at the time of the visit, coders should rely on the patient’s initial symptoms.
 
Consider the following outpatient coding rules:
  • 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. 
  • Coders may report chronic diseases treated on an ongoing basis as often as the patient  receives treatment and care for the conditions.
  • Code all documented conditions that coexist at the time of the encounter and that require or affect patient care, treatment, or management.
 
This tip was adapted from the article “The RACs are ready to go: Are you?” from the April  issue of Briefings on APCs.



Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular