If a diagnosis is mentioned in the patient record only once, should it be coded?


It’s understandable that you may be very weary to assign a code to a diagnosis in the record you see only once (and often times, only in the problem list). The best practice is to get all diagnoses in the record and problem list on a daily basis and to identify a plan of care and whether or not a diagnosis has resolved or is still being treated. You also may want to consider querying the physician when a diagnosis is only in the record once.

This question was answered in the 2018 edition of ICD10monitor’s Essentials for Clinical Documentation Integrity. For more hot topics relating to respiratory therapy services, please view our store, or call us at 1.800.252.1578 ext. 2.


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