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http://www.hcpro.com/content.cfm?dp=HIM&content_id=281424
Jun 20, 2012 · Principal diagnosis is not just “what got the patient off of the couch,” noted Gold. Sequencing diagnoses that qualify as principal. Circumstances of an inpatient admission always govern the selection of a principal diagnosis, Bryant noted.
https://www.hcpro.com/HOM-306284-5728/Coding-Clinic-reiterates-guidelines-for-provider-documentation.html
Jul 01, 2014 · Coding Clinic reiterates guidelines for provider documentation Association of Clinical Documentation Improvement Specialists, July 1, 2014. by Sharme Brodie, RN, CCDS . The AHA published its first issue of Coding Clinic for ICD-10-CM and ICD-10-PCS along with its final edition of Coding Clinic for ICD-9-CM. (Read the related article below.)
https://acdis.org/articles/qa-documenting-principal-diagnosis
Aug 30, 2018 · Q&A: Documenting the principal diagnosis . August 30, 2018. CDI Strategies - Volume 12, Issue 38. Q: I have a general question about how providers should list their primary and secondary diagnosis in their daily progress notes. I was taught the primary diagnosis should be listed as number 1 (first listed diagnosis) and then the other diagnosis ...
http://library.ahima.org/doc?oid=60174
Documentation and Data Improvement Fundamentals. Ruthann Russo, JD, MPH, RHIT . Introduction. The absence of complete documentation in patient medical records can have a negative effect on statistical databases, financial planning, clinical preparedness, and …
https://www.proactivemedicalreview.com/pdpm-operations-selecting-primary-diagnosis/
Nov 12, 2019 · CMS expects the principal diagnosis on the SNF claim to match the primary diagnosis in item I0020B. Contemplate periodic third-party reviews to validate claims and evaluate supportive documentation included in the medical record. Consider these Proactive tools and resources to assist with ICD.10 Coding Process Improvement:
http://library.ahima.org/doc?oid=106669
It is a common trait among physicians that they think they care for the sickest patients. Proper documentation can help support or debunk that claim. Educate physicians that hospital coding determines the severity of illness and risk of mortality. Thus, good clinical documentation benefits the physician as well as the hospital.
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2017-ICD-10-CM-Guidelines.pdf
guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official. The guidelines are organized into sections.
https://www.chegg.com/homework-help/questions-and-answers/documentation-support-principal-diagnosis-coding-superviso-vale-community-general-hospital-q32710055
Question: Documentation Support For Principal Diagnosis You Are The Coding Superviso At Vale Community General Hospital. An HIM Student, Rachel, Is Working With You Taday. She Is Looking At Some Charts And Has Asked You How You Determine If The Documentation Supports The Codes.
https://kanrisi.files.wordpress.com/2013/03/coding-guidelines-booklet_drg_416.pdf
DRG 416 — Septicemia ICD-9-CM Coding Guidelines ... Definition of Principal Diagnosis ... Coding And Reporting or replace physician documentation needed to support code assignment. (See Coding Clinic, second quarter 2004, page 13.) Drotrecogin alfa (activated) infusion
https://acdis.org/articles/qa-should-acute-respiratory-failure-be-principal-diagnosis
Aug 15, 2019 · So, acute respiratory failure can be coded if the condition meets the definition for the principal diagnosis and is clinically supported in the medical record by a hands-on treating provider without any conflict existing in the documentation between any consulting and attending provider.
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