Coding is full of complexity, and this doesn’t end with code selection. The official guidelines for reporting International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), the official guidelines for claim form completion, and the reality of how payers adjudicate claims must all come together to paint the picture of what services were provided and the conditions that prompted each service. Important pieces of this puzzle are

The combination of coding guidelines and instructions for completing the professional claim form can get a bit confusing. Appropriate payment depends on careful code assignment, linking, and claim submission. In this article, we will review documentation of the diagnoses for services rendered and appropriate linking of diagnoses to services.

As noted, the ICD-10-CM guidelines instruct that codes should be reported for all conditions that coexist and are managed or affect management during an encounter. Furthermore, the guidelines instruct to report first...

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