![]() ![]() The more specific your documentation, the easier it will be to defend your treatment plan. Your documentation of the history, subjective complaints and objective findings will indicate the proper diagnosis code to use. Therefore, the code you use on the claim form must be substantiated, documented and reported “to the highest degree of specificity.” Utilization guidelines in the software systems of many insurance carriers take the diagnosis codes and convert those into the probable number of treatments. The codes you put on the claim form and the order in which they are placed are your first line of communication with an insurance carrier. An essential rule in the coding guidelines is that the provider must code what they know and be as specific as possible when choosing codes. The World Health Organization (WHO) has established guidelines for coding conditions. Knowledge of proper coding techniques will help convey the whole story in case management, communication in the report of findings and proving medical necessity. Your documentation and coding must tell a story. Therefore, specificity is the word that most commonly relates to proper diagnosis code selection today. The codes you use will directly affect your reimbursement. do we use the coding system for reimbursement. The ICD statistical classification system is the most widely used in the world. It is hard to believe that ICD-10-CM, with nearly 73,000 codes, has now been used for over seven years in the United States. Likewise, most doctors are unaware of the impact choosing the most specific diagnosis has on its use in reimbursement and showing the medical necessity of treatment. In 1860, when Florence Nightingale first proposed a model of hospital data to keep statistics on the causes of death, little did she know it would eventually lead to ICD 10 coding guidelines and the ICD 10 coding system. With ICD 10 coding guidelines take into consideration how ICD 10 codes are processed
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