BC Advantage - 2016 Issue 4

DOCUMENTING SPECIFICITY FOR ICD-10 CODING

Specificity in documentation allows the most accurate ICD-10 codes to be assigned. Correct coding allows the office to paint a more accurate picture of the patient's diagnosis. For example: Laterality - Be sure your providers are clearly documenting laterality (left, right, bilateral) in the medical record along with clinically pertinent anatomical site(s) because over 1/3 of the ICD-10 codes contain laterality. For example: When documenting abdominal pain, include the following: 1. Location (e.g., Generalized, right upper quadrant, periumbilical, etc.) 2. Pain or tenderness type (e.g., Colic, tenderness, rebound) 1. R10.31 Right lower quadrant pain 2...

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