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Thread: documentation and coding compliance

  1. #1
    Join Date
    Apr 2007

    Default documentation and coding compliance

    AAPC: Back to School
    where can I get the documentation guidelines for physician to code for DM uncontrolled.
    Some physicians document A1C not at target /DM unc/DM OOC/DM not well controlled etc.,

    Unc : Uncontrolled
    OOC: Out of controll

    Above abbreviations are not approved by our facitlity.

    Thank you

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Unapproved abbreviations

    If the abbreviations are NOT approved by the facility then they can not get credit for documenting the condition.

    You must impress upon the physicians that their documentation must meet the standard set by the facility. If there IS an approved abbreviation for uncontrolled DM, get that to the physicians so that they can begin using it.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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