Oftentimes the way a provider thinks of the diagnosis description is different then the official diagnosis description provided by CMS and NCHS. Put simply, the billing diagnosis does not always match the clinical assessment. Moreover, when assessing a condition a generic description often fails to capture important distincts involved in the assessment (laterality, severity, accompanying conditions or modifying factors). Recording left knee pain brought on with exercise is more informative than knee pain OR severe wheezing relieved by inhaler offers more insight than wheezing.

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