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General Surgery Coding Alert

General Coding:

Be Specific, Not Leading, in Query

Published on Tue Feb 25, 2025

Question: In a recent encounter, a provider documented that a patient had a patient-health questionnaire-9 (PHQ-9) score of 14, which usually indicates moderate major depressive disorder. The provider also documented the patient having more severe symptoms and adjusting their medication accordingly. However, the provider documented a diagnosis of mild recurrent major depressive disorder. If I query the provider to ask [...]
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