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Wiki ICD-9 documentation

LUDS

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I've recently started doing some chart reviews. I've noticed many instances where the diagnosis is numerical format only. The charts are paper charts and the documentation is handwritten. I have seen this more from psych providers. In the event of an audit (say CMS) would this be considered appropriate documentation?
 
When you say "numerical form", do you mean they're just listing the ICD-9 code? How do they know they're picking the right one?:confused:

Brandi Tadlock, CPC, CPMA
 
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