NPSDEB
Networker
We just had an ICD 10 meeting with our physicians and we were discussing that documentation for ICD 10 has to be more specific. I pointed out that when they document the Pre and Postoperative diagnosis on the op report they have to list the diagnosis as they did for the consult. For example patient is coming in for breast reduction for back pain, neck pain, shoulder grooving and intertrigo. All of these diagnosis were listed in the initial consult for the patient. When they dictate the operative report they just say "symptomatic macromastia" for both pre and postoperative diagnosis. We are wondering if we have to relist the reasons for the surgery (back/neck pain, ect) or if the macromastia is enough. Or if they document "as documented in my previous notes" if that will be enough.