Using the Right Diagnosis

by  Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
May 13th, 2016

One of the hardest parts when reviewing a medical record for coding or auditing is the determination of what conditions were addressed. Any condition that is taking into account or affects patient care, treatment or management should be documented and ultimately coded. However, the documentation still needs to support that the provider did in fact review, consider, or treat a condition in order for it to be supported. And whether it is supported affects more than just what ICD-10 code ends up on the claim. Showing the additional work affects the overall medical necessity of the visit, the level of medical decision making, and ultimately, the level of service that is supported. In addition, as many hospitals and clinics are becoming accountable care organizations, the right diagnosis becomes paramount in receiving appropriate reimbursement for the care of the patient.

Making the right diagnosis selection relies on using proper documentation that supports the most accurate representation of the condition. Many coders and healthcare workers will be quick to mention the giant gap in what is clinically significant and how it translates into coding. To assist in closing the gap, consider the following points.

When choosing your diagnosis code:

Resolved problems or past history:

Documenting undiagnosed conditions:

Diagnoses with cause/effect relationship or manifestations:

Making the right diagnosis selection with proper documentation will support the more complex level of medical decision making, and will allow the provider to accurately capture the value of the work they performed.

Using the Right Diagnosis. (2016, May 13). Find-A-Code Articles. Retrieved from

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