When determining the diagnosis code what is the first step?
Locating the diagnostic statement.
Determining the main term in the diagnostic statement.
Asking the provider for the diagnostic statement.
None of the above.
The Correct Answer and Explanation is :
The correct answer is “Locating the diagnostic statement.”
Explanation:
When determining the diagnosis code for a patient, the first step is locating the diagnostic statement. The diagnostic statement refers to the clinical conclusion about the patient’s condition, which is usually made by the healthcare provider based on the patient’s symptoms, medical history, and test results. This statement is typically found in the patient’s medical record, including the physician’s notes, discharge summaries, or other documentation.
Here is a step-by-step breakdown of how the coding process generally works:
- Locating the Diagnostic Statement: Before anything else, you need to identify the condition or disease that is being treated or evaluated. This diagnostic statement provides a clear and concise description of the patient’s health issue. For instance, a physician might write, “Patient diagnosed with type 2 diabetes mellitus,” which is the diagnostic statement.
- Determining the Main Term: After locating the diagnostic statement, the next step is to identify the main term in the statement. The main term is usually a noun or a key medical term that defines the condition. For example, in the statement “Patient diagnosed with acute bronchitis,” the main term is “bronchitis.”
- Consulting the ICD Codebook: The next step involves using the main term to find the appropriate code in the International Classification of Diseases (ICD) codebook. This book is an essential tool for medical coders and provides a systematic list of codes that correspond to various medical diagnoses and conditions.
- Assigning the Correct Diagnosis Code: Once the main term has been located in the ICD codebook, the coder will review the available options and select the most accurate diagnosis code, based on the specifics of the case, including the severity, location, or other characteristics of the condition.
In summary, while it may seem like the coder would begin by determining the main term or asking the provider for clarification, the first critical step is to locate the diagnostic statement to ensure accurate coding.