From the textbook, Case Studies in Health Information Management, follow the instructions to complete case 2-3 Documentation support for Principal Diagnosis. Use Official Coding Guidelines as support when appropriate
Create a policy and procedure which includes a step-by-step process addressing the UHDDS standards and Official Coding Guidelines. Your policy and procedure should also address other official sources of coding guidance such as Coding Clinic, CPT Assistance, CMS, AMA, and NCCI (when and how they should be used)
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