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Coding Tip: Diagnosis Reporting on Outpatient Records

Outpatient coders may not code from laboratory reports unless the physician has made a notation regarding the findings with a diagnosis from the laboratory results. This guidance did not change with the implementation of ICD-10 but there still are a lot of questions regarding this. The recent AHA Coding Clinic for ICD-CM/PCS does confirm that

Actived: 7 days ago

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Coding Tip: “Code First” Instructional Notes in ICD-10-CM

In this case, the PDX/first listed code will be the lung cancer followed by the code for the malignant pleural effusion. In the ICD-10-CM tabular, the coder will see notes under the …

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Coding Tip: Coding and Reporting of Signs and Symptoms

Signs and symptoms are acceptable if no cause for them has been established by the provider. If there is a combination code that includes the symptom, an additional code for the symptom is …

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