Medical Assistant Prep / Unit 26 MAS 638 worked example, 60 to 90 seconds
Finding a Diagnosis Code
The idea
The official coding guidelines describe a two-step process for finding a diagnosis code, with careful reading at each step.
In practice
Step one: find the main term for the documented condition in the Alphabetic Index. Step two: note the code the index points to. Step three: verify that code in the Tabular List, the numbered list of codes. Step four: read the instructional notes in both the index and the list, which can require additional codes or exclude others. Step five: assign the code to the full number of characters required.
Where people slip
Never code from the index alone. The Tabular List contains instructional notes and required extra characters that the index does not show, and those notes can change which code, or how many codes, the visit needs.
Your place on the trail
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