ICD-10-CM Documentation 2019 : Essential Charting Guidance to Support Medical…

ICD-10-CM Documentation 2019 : Essential Charting Guidance to Support Medical…

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ICD-10-CM Documentation 2019: Essential Charting Guidance to Support Medical Coding Accuracy

In order to ensure accurate medical coding and billing, healthcare providers must adhere to strict documentation guidelines outlined in the ICD-10-CM coding system. Proper documentation not only helps healthcare professionals accurately assign diagnostic codes, but also plays a crucial role in patient care, reimbursement, and quality reporting.

Here are some essential charting guidance tips for healthcare providers to support medical coding accuracy in 2019:

1. Provide Specific and Detailed Descriptions: Documenting specific details about the patient’s condition, symptoms, and any relevant factors is crucial for accurate coding. Avoid using vague terms or abbreviations that may be open to interpretation.

2. Include Relevant Diagnostic Tests and Results: Make sure to include the results of any diagnostic tests or procedures performed, as well as any follow-up recommendations. This information can help support the medical necessity of the services provided.

3. Document Coexisting Conditions: It’s important to document all coexisting conditions that may impact the patient’s care and treatment. This includes chronic conditions, comorbidities, and complications.

4. Use Official Terminology: Healthcare providers should use the official terminology and documentation guidelines provided in the ICD-10-CM code set. Avoid using outdated or non-standard terminology that may lead to coding errors.

5. Include Timeframes and Progress Notes: Documenting the timeframe of the patient’s symptoms, treatment, and progress is essential for accurate coding and billing. Regular progress notes can help track the patient’s response to treatment and any changes in their condition.

By following these essential charting guidance tips, healthcare providers can ensure accurate documentation that supports medical coding accuracy in 2019. Proper documentation not only benefits the provider in terms of reimbursement and compliance, but also enhances patient care and outcomes.
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