I would go back to the provider with ICD-9 code book in hand and show him/her the code I think it would be and explain why I think that based on their documentation and then ask if they would like to change their coding. Alot of times the physicians aren't aware there is a code that specific. It all goes back to provider education. I have instructed the providers I work for to write the diagnosis out for me rather than circling it on the encounter form so I can find the code that best fits. For example on our encounter form it says pain specify site________________ my providers would write shoulder pain and rib pain this way I can find the appropriate code to code to the highest degree of certainty.
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