Pam - you're correct.. however not every coder is so experience that they can tell right off what can be coded and what can't thus then need for documentation, yes?
"We report those conditions stated in all related physician documentation that would/could impact treatment of the current condition. We also include history, if it's relevant to the current care"
You mean in the entire medical record? what if only the record for the encounter in question is available? that means we need clear documentation, correction?
thank you, !!
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