Who is the provider in the ICD 10 cm guidelines?
The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.
What should be included in a summary of a diagnosis?
The summary must draw on all areas in the earlier parts of the report. New information cannot be introduced. Features may be drawn from all aspects of the history and examination, and should include relevant negatives (features of the diagnosis and differential diagnoses that are not present).
What are the considerations in the diagnostic process?
The chapter describes important considerations in the diagnostic process, such as the roles of diagnostic uncertainty and time.
When does diagnostic refinement become diagnostic verification?
As the list becomes narrowed to one or two possibilities, diagnostic refinement of the working diagnosis becomes diagnostic verification, in which the lead diagnosis is checked for its adequacy in explaining the signs and symptoms, its coherency with the patient’s context (physiology]
The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.
How is diagnosis code assignment based on clinical criteria?
“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”
Are there still reporting criteria for uhdds patients?
The UHDDS reporting criteria are still valid, alive and well. Refer to Section II “Selection of Principal Diagnosis” and Section III “Reporting Additional Diagnoses” of the Official Guidelines for Coding and Reporting.
