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Guidelines for Diagnosis

Francisco Posted Wed 19th of August, 2015 16:28:09 PM

Can you tell me if we are required to keep old diagnosis along with new ones? (continue to show all diagnosis) when billing for a new diagnosis? I thought CMS guidelines required us to show old dx. for continuity of care. Can you please advise? Office staff is confused. Thanks

SuperCoder Answered Thu 20th of August, 2015 01:58:48 AM

The documentation should include the final diagnosis, condition, which is still present in the patient or the history of ICD-9 code, which can indicate that patient had the specific disease.

If the diagnosis was not confirmed, the documentation should include the Rule-out, versus, probable, possible, differential, suspected, working, etc. terms relating to the diagnosis (undeveloped as yet diagnosis: awaiting further study): in these instances,
code the most specific signs/symptoms, exposure to, personal or family history of diagnosis that applies.

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