Coding Steps - Step 3 Verify the Code in the Tabular List...

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Coding Steps Step 1 Determine the Reason for the Encounter Code the primary diagnosis first, followed by current coexisting conditions. Code to the highest level of certainty. Code to the highest level of specificity. Step 2 Locate the Term in the Alphabetic Index The main term for the patient’s primary diagnosis is located in the Alphabetic Index. These guidelines should be observed in choosing the correct term: Use any supplementary terms in the diagnostic statement to help locate the main term. Read and follow any notes below the main term. Review the subterms to find the most specific match to the diagnosis. Read and follow any cross-references. Make note of a two-code (etiology and/or manifestation) indication.
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Unformatted text preview: Step 3 Verify the Code in the Tabular List The code for the main term is then located in the Tabular List. These guidelines are observed to verify the selection of the correct code: Read include or excludes notes, checking back to see whether any apply to the codes category, section, or chapter. Be alert for and follow instructions for fifth-digit requirements. Follow any instructions requiring the selection of additional codes (such as code also or code first underlying disease). List multiple codes in the correct order. Code the Primary Diagnosis First, Followed by Current Coexisting Conditions...
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Coding Steps - Step 3 Verify the Code in the Tabular List...

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