Although we are all in the health-care field, there is significant variance between the clinical and the coding worlds. Providers are not coders, which can result in documentation that can be referred to as “doctor-speak,” not “coding-speak.” Understandably, this difference can cause confusion, such as when inconsistencies regarding diagnosing current and historical conditions occur in the medical record. It is a longstanding practice for providers to use ‘History of’ when referring to a patient’s past conditions, whether they be…
Category Archives: "Coding"
Documenting Major Depressive Disorder
By Denise Wills, CPC-A
When documenting depression, accuracy is important in determining the most specific code. If incomplete documentation is received, it will result in an unspecified code selection, which does not map to an HCC. For example, ICD-10 code F32.9 (MDD, single episode, unspecified) does not map to an HCC, whereas F32.0 (MDD, single episode, mild) does.
The ICD-10 classification of Mental and Behavioral Disorders, developed in part by the American Psychiatric Association, classifies depression by code. Documentation of Major…
Coding for Diabetes in ICD-10
By Lynn Diorio, CCS-P, CRC
Risk Adjustment Coder
Coding for diabetes can be a daunting process. Clear and concise documentation by the provider is key in helping to ensure that the condition is captured appropriately. There are five major categories that diabetes can fall into in ICD-10: Type 1 (E10); Type 2 (E11); Diabetes due to underlying condition (E08); Drug or chemical-induced (E09); and other specified (E13).
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