Ccgerson
Guest
I'm new to coding, just became CPC-A certified. My first question is related to ICD 10. When reading a medical record, if physician doesn't specify episode of care , but it's apparent in context of record what the episode of care is, can I code based on that? Or does physician need to document "initial, subsequent , sequelae".
Also, if documentation of the diagnosis is missing an element, however that information can be found elsewhere in the medical record , is it appropriate to code? For example , physician documents diagnosis as : sleep apnea. You see in history that patient has history of obstructive sleep anea. Can I code OSA?
Another example, physician documents diagnosis as "obesity ". You see in the medical record that patient has a BMI that places them in cAtegory of "morbid obesity ". Can I document morbid obesity? Or does physician need to modify his documentation ?
Thank you
Also, if documentation of the diagnosis is missing an element, however that information can be found elsewhere in the medical record , is it appropriate to code? For example , physician documents diagnosis as : sleep apnea. You see in history that patient has history of obstructive sleep anea. Can I code OSA?
Another example, physician documents diagnosis as "obesity ". You see in the medical record that patient has a BMI that places them in cAtegory of "morbid obesity ". Can I document morbid obesity? Or does physician need to modify his documentation ?
Thank you