How do you ensure specificity when selecting a diagnosis from a general note?

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Ensuring specificity when selecting a diagnosis from a general note is essential for accurate coding, reimbursement, and data quality. Here’s how to approach it effectively:

🔍 1. Thoroughly Review the Entire Note

Read the entire clinical record, including:

• History and physical (H&P)

• Assessment and plan

• Diagnostic test results

• Progress notes

This helps uncover detailed clinical clues not clearly stated in one section.

📌 2. Focus on the Provider’s Assessment

The Assessment and Plan section typically contains the most precise diagnoses. Coders should prioritize what the provider explicitly documents, not just what is implied.

🧠 3. Use Clinical Clues for Clarification

If the diagnosis is general (e.g., “infection”), look for:

• Site (e.g., “urinary tract infection” vs. “infection”)

• Cause or organism (e.g., “E. coli UTI”)

• Type (e.g., “acute,” “chronic,” “recurrent”)

Cross-reference lab results, imaging, and medications to support specificity.

❓ 4. Query When Necessary

If specificity is not clear, initiate a compliant query to the provider. Ask for clarification without leading the answer.

📚 5. Use Coding Guidelines & Tools

Refer to ICD-10-CM guidelines to match terms with the most specific, appropriate code. Use encoder tools or coding references for additional support.

✅ 6. Avoid Assumptions

Never infer a diagnosis. Only code what's documented or confirmed by the provider.

In summary, specificity is achieved through careful documentation review, clinical correlation, and provider clarification when needed—all while adhering to official coding standards.

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