vendredi 20 novembre 2015

I-10 coding from impression & recommendations

I have been told if the provider list/documents a diagnosis/problem/condition in the "impression & recommendations" (similar to plan or assessment)area of the EMR, the coder HAS TO code this diagnosis. example:

Problem 1 COPD - treated antibotic prescription
Problem 2 GERD - treated PPI prescription
Problem 3 Pseudomonas infection - treated antiboitc prescription as above
Problem 4 Cholelithiasis - as per Dr. Jones

I would code just the first three problems because he treated/addressed those, but I would not code problem 4 and it does not matter that it is listed under the "impression & recommendations" area of the record.

Any thoughts?

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I-10 coding from impression & recommendations