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ICD-9 documentation

  1. #1
    Question ICD-9 documentation
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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?

  2. #2
    Medical Billing
    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?

    Brandi Tadlock, CPC, CPMA

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