When the new coding guideline for clinical validation went into effect October 1, 2016, the stakes were raised higher for the diagnoses documented by the physician to be clearly and consistently demonstrated in the clinical documentation.
Unclear code descriptions and undefined diagnostic terms abound in ICD-10 CM. How are coders and CDI specialists to know what do do?
Many a coder has run across the diagnosis "altered mental status" on a patient chart and then scratched their head. How do I code that? It is all about the documentation.