tci General Surgery Coding Alert - 2015 Issue 10

Reader Question: Distinguish Chronic, Acute in Medical Record

Question: Does ICD-9 have a default way to code acute versus chronic if the medical record does not specifically document the distinction? For instance, if the doctor just writes “Cholecystitis,” what is the best way to determine acute versus chronic? California Subscriber Answer: If the medical record doesn’t document a condition as “acute” or “chronic” but the codes have those options, you’ll typically see that one of the codes states, “unspecified” or “NOS,” which means “not otherwise specified.” If the physician’s documentation doesn’t state “acute&rdquo...

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