It would definitely help if the doc was more specific. The following is an excerpt from the Official Coding Guidelines. Show it to your providers and maybe that will help with their future documentation.
"Abnormal Findings" Abnormal findings (lab, path, etc) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the abnormal finding should be added"
It is all in the documentation
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join