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Wiki ICD-10 dx codes for sketchy documentation

jennyaharvey

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Location
Knoxville, TN
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I'm auditing a provider that does not come out and state a diagnosis for any notes that I've reviewed so far. For context; the patient has a cochlear implant and complains that he can't understand what people are saying in conversation. A hearing evaluation was completed and the conclusion summary states: "The results indicate that [patient] has significant difficulty in understanding speech in quiet." Would you assign a dx code or not?
 
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