diagnosis documentation

  1. H

    Wiki Surgical amputation (can it be coded as traumatic?)

    If the amputation was surgical, can we still report the traumatic amputation codes? Example, S98.11A (Complete traumatic amputation of right great toe initial encounter) since there is no code that specifies complete SURGICAL amputation of right great toe initial encounter. (Coding for wound...
  2. M

    Wiki Help with documentation

    We have a new medical provider who does not state the diagnosis or symptoms in his notes. The diagnosis codes are selected by the provider from a drop down list on another page, but not stated in the documentation portion of the note. My job is to determine the level of E/M and I'm worried about...
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