A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity.
Per ICD-10 official guidelines for reporting and coding, “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”
Documentation & Coding Tips
Documentation needs to be clear and detailed using the following terms to allow accurate ICD10 code selection.
Specificity:
- Episode: current or most recent
- State: hypomanic, manic, depressed, or mixed
- Severity: mild, moderate, severe, severe with psychotic features
- Status: partial remission, full remission