Reportable diagnosis and surgical procedures documented

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Question

Are all reportable diagnosis and surgical procedures documented by the physician to the extent of specific coding (that would affect the reimbursement)? If yes, complete the coding in 3M and save a copy of your abstract. If no, if you found conflicting documentation or inadequate documentation for specific coding:

1. Will additional documentation for more specific coding affect the reimbursement? (Check it in 3M).

2. If yes, complete a query form and two 3M abstracts. You should complete one 3M abstract for the original codes (before you query), and one abstract to show what the coding would look like if the provider responds positively to your query. These two abstracts should show the DRG change/impact from your query.

Reference no: EM133793652

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