Topic: When the Diagnosis is Unclear

Speaker: Beth Schleeper

Webinar Description:

What happens when a diagnosis in the documentation is not clearly defined? Coders, auditors, and billers face the challenge of ensuring accurate and compliant coding when dealing with ambiguous or incomplete documentation. This webinar will explore the correct steps to take, focusing on compliant physician query practices, abstracting techniques, and strategies for resolving unclear diagnoses. Attendees will learn how to ensure documentation clarity without overstepping compliance boundaries, keeping patient records and billing accurate and compliant.

Learning Objectives:

1. Compliant Physician Queries: Understand when and how to issue compliant physician queries to clarify ambiguous or incomplete diagnoses while adhering to regulatory guidelines.

2. Abstracting Essential Information: Learn compliant abstracting techniques that help identify and extract key clinical information from the documentation to support coding decisions.

• Handling Ambiguous Diagnoses: Gain insights into best practices for handling unclear or insufficiently defined diagnoses in the documentation to ensure proper coding and billing.