ICD-10: Your Physician's Notes Reveal Diagnosis Codes -- You Just Have to Know Where to Look

Why This Topic Matters

Incomplete diagnosis information can affect claim accuracy and internal coding consistency. The article is relevant to coders and physician offices that rely on documentation review to support ICD-10-CM reporting.

Article Sections

1. Open the Notes When You Have to — and Even When You Don’t

   Discusses using physician documentation and office policies to address missing diagnosis information on a superbill. It also covers internal review practices and the role of coder-physician communication.

2. When in Doubt, Confirm With the Physician

   Focuses on verifying diagnosis selection with clinicians when coders are still building familiarity with ICD-10-CM and local documentation practices. It emphasizes the importance of office policies for handling missing diagnoses.

3. Check the Notes for Clues

   Presents a documentation-review example involving a spine-related encounter and the use of ICD-10-CM references to narrow diagnosis coding from the chart note and assessment.