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Wiki Coded Diagnosis Doesn't Meet Reporting Criteria

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foster8488

foster8488

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Good morning! I recently started a new role at a new organization. It's my responsibility to determine how to address diagnoses that providers are coding when they don't meet reporting criteria. For example, a provider sees a patient for alcohol dependence (which is evaluated/addressed with a progress note), but the provider codes both alcohol dependence and anxiety. The anxiety wasn't mentioned anywhere in the provider's progress note.If I were the coder, I would've simply coded the alcohol dependence and disregarded the anxiety diagnosis since it does not meet reporting criteria. However, it's already been coded by the provider. How would you address this with a provider?
  • Is a query appropriate? If so, what would you be asking in the query?
  • Is a query not appropriate? If not, how would you address this with the provider?
 
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