AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2015 Issue 4; Ask the Editor

Code Number in Lieu of a Diagnosis

Since our facility has converted to an electronic health record, providers have the capability to list the ICD-10-CM diagnosis code instead of a descriptive diagnostic statement. We are seeking clarification for whether there is an official policy or guideline requiring providers to record a written diagnosis in lieu of an ICD-10-CM code number? ...

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