Essential Coding and Reporting Basics
Diagnostic statement should include applicable specificity to Remember
Verify and record patient name and date of birth
Record the date of service of the clinical encounter
Include provider’s full name, credentials and signature
Code to the highest degree of specificity based on documentation in the record
Document all applicable symptoms and related history
Document all applicable exam, laboratory, and imaging findings
Document a treatment plan for reported conditions
Report only confirmed diagnoses in an outpatient setting with a diagnostic statement compatible with ICD-10 nomenclature
Report telehealth services with applicable place of service codes and modifiers, including documentation of the audio-visual encounter
The ICD-10-CM Official Guidelines for Coding and Reporting are the primary source for diagnosis coding guidance
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2023 Medicare Advantage Partnership Guide
Welcome
Contents
Documentation Best Practices
2023 Medicare Advantage ICD-10-CM Quick Reference Code Guide
Disease-Specific Webinar Links
Conditioning Reporting Guide
Reporting Common Conditions
Atrial Fibrillation
Cancer
Chronic Kidney Disease (CKD)
Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure (CHF)
DVT and PE
Dementia
Diabetes Mellitus (DM)
Major Depression
Obesity
Peripheral Artery Disease (PAD)
Substance Use/Abuse/Dependence
Tobacco and E-Cigarette Use/Abuse
Social Determinants of Health