![]() When an issue with underdosing is noted, document if the matter is new or has been recurrent. “Underdosing” is a new concept in ICD-10-CM and can be captured along with the diagnoses, such as this case for metoprolol succinate. If known, it is important to document whether or not patients are compliant with their medications. Summary of ICD-10-CM Impacts Clinical Documentationĭocumenting why the encounter is taking place is important, as the coder will assign a different code for a routine visit vs. Reevaluate HTN 4 in 3 days if improving then clear for surgery.Provided 30 day supply of free propranolol samples. Change to propranolol 20 mg, 2 tab PO daily, first dose administered in office.Smith as unclear if he was aware of financial situation HTN 4 is likely due to patient’s noncompliance with metoprolol succinate.Will have PCP monitor BUN & Creatinine for renal function and nephrology referral if necessary.Labs show creatinine at 1.5, a slight increase from his baseline and possibly indicating early renal insufficiency 3.Vitals taken BP is elevated at 157/92.Height and weight are appropriate for age. Patient is an 81 year old male in no acute distress.Has history of essential hypertension and was prescribed metoprolol succinate once daily by PCP, but patient is not taking as he cannot afford it 2.No history of cerebrovascular disease.Regular physical activity includes walking, swimming, and golfing.Inferior wall MI one year ago, received thrombolytic therapy and experienced complete resolution of his symptoms.Smith requested evaluation for hypertension and cardiac clearance assessment for surgery 1. 81 year old male scheduled for a TURP in 5 days.Smith asked that you check my hypertension prior to my surgery.” Scenario 1: Hypertension / Cardiac Clearance The clinical concepts for cardiology guide includes common ICD-10 codes, clinical documentation tips and clinical scenarios. Each scenario is selectively coded to highlight specific topics therefore, only a subset of the relevant codes are presented. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty.The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10 code selection.
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