The 2015 Long Term Care Coding Guidelines (adapted for long term care settings), assists coders in long term care facilities to make consistent and accurate coding decisions. The many features of these guidelines include:
ICD-10 CM Guidelines for Coding Diagnoses
Tips on Admission Coding, Concurrent Coding, Discharge Coding.
Assignment of Principal, Secondary Diagnoses.
Basic coding principles adapted to the long term care setting.
RAI/MDS 3.0 Resident Assessment Instrument implications by specific body system and/or conditions that appear on the instrument or in the MDS 3.0 Reference Manual Section I – Disease Diagnoses.
Physician coding for Billing Purposes
Guidance in all areas of the ICD-10 coding book including Diseases, Abnormalities, Signs/Symptoms, External Causes, Factors influencing health status.
And much more!
These guidelines should not be considered all inclusive nor should they be considered departmental policy. Each health information management professional is advised to develop his/her own internal coding policies using the guidelines as the basis. All policies should be reviewed by the medical staff and administration. Final approval of policies by the facility administration is recommended.