You have requested access to member-only content.

Examine documentation for clinical indicators that provide context for MCCs

Coders are constantly analyzing documentation for clues and details that may indicate the need for a physician query. For example, coders should watch for clinical evidence that points to a condition that the physician may not have explicitly documented. Coders also need to be wary of reporting conditions without accounting for context or other clinical indicators in the documentation. William E. Haik, MD, CDIP, explains how this can lead to inappropriate reporting of an MCC, for example, that the overall clinical picture does not support.

This is an excerpt from member-only content. Please log in or become a member.

Not a member? Let's fix that!

JustCoding is the continuing education website for coding professionals. Whether you're an inpatient or outpatient coder, a veteran or new to the job, JustCoding will keep your skills sharp, test your coding knowledge, and help you stay abreast of CMS changes.

Register to access the free content available through the JustCoding site or subscribe to a Basic or Platinum membership to access paid content on this site. Click here for more information.

For questions and support, please call customer service: 800-650-6787.