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Video instructions and help with filling out and completing Can Form 2220 Diagnostics

Instructions and Help about Can Form 2220 Diagnostics

One of the questions that we get from new students is knowing when you can and cannot code a diagnosis I think a lot of students as soon as they learn how to look up codes they are ready to code everything that they see and every every new student does it I remember I did it I was I want to call myself a super coder because I I wanted to code everything it's fun to code but you can't do that you need to code only definitive diagnosis and they can be hard to identify one of the things that you have to stay away from is equivocal language when we say equivocal language that means it's kind of on the fence it's not a definite it could go one way or the other you have to stay away from that type of verbage impending or threatened conditions you'll see that but that can be tricky you cannot code something if it has not happened yet in most cases now I know that sounds again a little ambiguous but if your physician documents for example will scroll down here just a bit impending rupture of spleen due to enlarged spleen okay impending tells you it's gonna happen they're pretty sure it's going to happen but it hasn't happened yet so you cannot code a ruptured spleen you can only code the splenomegaly which is an enlarged spleen seven eight nine point two that's the proper code to use now I've got some more examples for you so we'll scroll down and look at some of these others okay if your physician documents something like this mrs. Jones is seen today with lower abdominal pain and spotting I will admit her for threatening a threatens miscarriage okay so you're now saying to yourself well she hasn't had a miscarriage it hasn't happened yet but in actuality there's a code for this because it's such a common event you can however code six four zero point zero and you'll need a fifth digit it does not matter the the miscarriage has not occurred yet there is a code for a threatened to miscarriage because that is a medical condition if there had not been a code for that then you would have to code the signs and symptoms the spotting and the abdominal pain okay we've got some more things to look at here words that you want to pay attention to possible may be suspect rule-out probable expect apparent perhaps conceivably possibly now if you're coding and you're coding in an office that you have repetitious documents from specific doctors and you see them all the time you'll learn what verbage they use but if you're doing something like remote coding or multiple physicians it may be a little harder and you have to kind of get to know how they like to document how they like to work things these are some words that just popped up in one day of remote coding that I was doing and it gets to be kind of humorous sometimes we have to do a second take and say you know what what did they say if they think maybe so scroll down just a little bit more I've got some more examples okay these terms mean your physician does not know or is waiting for more testing if the statement is made this is another little case mr. green has been feeling tired thirsty and as making frequent trips to the bathroom it's apparent he has DM since his father and mother both had DM by age 50 we will draw labs today he is to return in one week for the results now the fact that he said it's apparent he has diabetes he didn't actually say that he has diabetes he said it's apparent that he has diabetes and then he confirms that he's not sure because he's going to do a test and have him come back for the results you have to be very careful if you gave this gentleman diabetes the way you coded it's gonna follow him for the rest of his life and he could have problems in the future maybe even getting jobs or life insurance policies because they do look at your your medical information to determine stuff like that have to be very very careful he might just have a bad cold and be real thirsty okay so another example mr. white is seen today with some am a sights and a chief complaint of dips Nia he stated he had been waking up at night with a dry cloth he has a history of CHF and microvascular spasms this is probable for cardiomyopathy physical exam reveals mild acetates tachycardia peripheral edema and cool extremities previous diagnostic testing was was reviewed which confirmed cardiomyopathy until he said which confirmed cardiomyopathy you're not allowed to code that because he doesn't have it until he stated he get confirmed what he was suspecting cardiomyopathy but all the verbiage before that was all suspect so pay attention to the details in your documentation don't ever jump to conclusions and it's very hard when you first start out not to jump to conclusions it's gonna get you in trouble when you're testing especially because some of those questions are specifically written to see if you're paying attention I know if I wrote a test question that's like throwing in not in a test question how many people are not feeling well today you know or something like that so pay attention those little words will cut you get more CPC exam tips coding certification training and CEU credits go to WWE certification or you.

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