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    Wiki Question on Medical Record Documentation

    Hello, I have some questions related to documentation by provider when abstracting or auditing the current medical documentation. 1. If the patient is dealing with a ongoing illness(chronic condition) but treated by another medical specialist doctor should the current physician list it under...
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    Wiki Z91 Noncompliant Diagnosis Code and Z59 Homelessness Dx Code

    Hi I know the Z91 block of diagnosis codes give reasons why patients are noncompliant in not following the clinical providers orders. The patient could not follow due to refusing take medications given, or not follow a diet plan, or refuse to agree to the medical plan given or suggestion to...
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    Wiki How to add new diagnosis codes for the ICD10 manual ?

    Hi Everyone, I wrote a letter to the WHO and AMA agencies a few years ago asking to add a Cough diagnosis for use for children or young teens. Of course I got no reply. However I think the illness symptom of Cough for specifically children would be a great addition. I have some other...
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    Wiki Secondary Diagnosis codes

    Hello I am wondering when you would assign the diagnosis worded as "Secondary" diagnosis codes such as E85.3, I27.29, and I15. Check those out in your ICD10 manual. Would you assign these when the physician states in his documentation this is a secondary medical concern or when it is listed as...
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    Wiki Rehab Inpatient Coding & Billing Questions

    Hello I have some questions regarding billing & coding rehab inpatient service. If you can respond back to me I d really be thankful. #1 Can a patient have more than one impairment code on the IRF-PAI form related to their POA and illness arriving with? There are 16 impairment codes and not...
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    Wiki Diagnosis Coding regarding Inpatient Admissions

    Hello This question is geared for coders process inpatient admissions diagnosis codes. If the hospitalist or attending physician list 4 or 5 diagnosis codes for the patient for the day of treatment while doing a subusqent hospital visit should not the coder list all diagnosis given? I know...
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    Wiki Medical Coder Job Annoyances while abstracting

    Hi Everyone If you working as a professional medical coder now. I am just wondering what are your on the job annoyances or pet peeves? Do not get me wrong I LOVE this career as medical coder. It is so very interesting and at times challenging career. However my reason for asking is to create...
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    Wiki Coding over 12 diagnosis codes for outpatient setting

    Hi While completing outpatient coding uses a CMS 1500 form which will not allow over 12 diagnosis codes. At times my provider gives over 12 dx codes. So I must remove some dx codes listed. I remove the ones in which he gives the dx description as stable or another physician is taking care of...
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    Wiki HIPAA Violation of sharing staff job logins??

    Hello Does anyone think sharing staff logins to show transmitting of insurance claims and creating fiscal reports and posting payments is in violation of the HIPAA Security Rule ? :confused:
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