Q. How do I talk to my providers about the documentation to support specific International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes when most of them do not really know the codes, but they know the terminology? A. Now that we are 1 year into using ICD-10-CM codes, most expect the Centers for Medicare & Medicaid Services (CMS) to lift the grace period for allowing providers to assign unspecified diagnosis codes. It is …
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Probe Deeper if Symptoms Just Don’t Add Up
It was a case that easily could have presented in any urgent care center, and one that shows the importance of probing beyond social and medical history, including a patient’s profession and hobbies if necessary. The patient presented with a 7-year history of breathing difficulty that had recently worsened. The only related detail seemed to be that he had been diagnosed with hypersensitivity pneumonitis (HP, also known as farmer’s lung and hot tub lung) 5 …
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