Wiki Question on coding +

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kpeterson15

kpeterson15

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Hi Everyone,

I read in the CRC study book we cannot coded when the provider using + to show positive. Is this true and if so any resources I can be led to about this? I do not have my book anymore to show my leads on my team, but I just want to make sure I am coding correctly when it comes to coding +. For example I will see provider put "+UTI" or "+ Adenovirus". We are being told to code them, but I just wanted to make sure we can code them as a positive result like this.
 
Auditors or providers' office management may educate providers pertaining to short cuts such "+", "-", "wnl", "=". However, the reason behind providers' use of short cuts is scarcity of time. It might be not very visual for documentation review on IC side, but claims usually get paid.
EPIC system, if in use, allows to save common phrases and utilize them for chart documentation.
 
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