Q: What is the proper code for “Lumbar Decompression?
Generating a differential diagnosis — that is, developing a list of the possible conditions that might produce a patient’s symptoms and signs — is an important part of clinical reasoning. It allows a provider to perform appropriate testing to rule out possibilities and confirm a final diagnosis.
Courts view the formulation and documentation of a differential diagnosis as evidence of a physician’s competence, prudence, and thoughtfulness.
In some places, the ICD-10-CM code set uses words we think we are familiar with. However, a review of the guidelines shows that some of these words have very specific definitions. Here are a few important ones to remember.
Here at ChiroCode we often get to look at doctor records and provide advice on ways to improve them. One of the main issues is lack of functional progress to establish medical necessity. That may sound like a mouthful, but it is not hard to make sure it is clear in a typical note. Learn about an actual case that was documented well, but still had room for improvement.
Ever wondered how to code for wellness visits. Even though they are typically not billed to third parties, there is a right way to record these kinds of encounters.
How do you code for a bilateral condition, such as sciatica?
How do we know which codes a payer will allow?
Chapter 20 External Causes of Morbidity includes codes from V00 to Y99. They were greatly expanded in ICD-10-CM.