AHIMA Professional Practice Experience Workbook

4. 5. 6.

Treatment Provided:

Link to Dx #

1. 2. 3. 4. 5. 6.

Assess accuracy/completeness of documentation: Are all documents legible?

(Y/N, if no, list problems)

Is additional documentation needed to support diagnoses (as documented by physician, or possible diagnoses identified by coder)? (Y/N) Propose wording for compliant physician query, if needed.

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