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Wiki documentation post ICD10 grace period

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glomaxie

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With the grace period for documentation/coding issues for ICD10 ending effective 10/1/2016---can someone please clarify for me if our physicians (rheumatologists) are also required to be very detailed with documentation and coding for an illness that is outside of our treating of the patient, but may be relevant to her medical history, current complaint, etc.. Such as: glucose intolerance or chronic kidney disease. In other words---are we expected to provide the most detailed diagnosis for these sort of illnesses---or are we allowed to "default" to an unspecified code?
 
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