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For hemiplegia and hemiparesis and other paralytic syndromes, report the affected side as dominant if the documentation does not specify which side is dominant.
When reporting an infection that is antibiotic resistant, report the infection first followed by Z16, Infection with drug resistant microorganisms.
Diabetes mellitus codes are combination codes that include the type of diabetes as well as the body system involved and complications affecting the body system.
If the medical documentation indicates the patient has two conditions that are both included in one diagnosis code, report that diagnosis code only once.
Multiple coding is when it takes more than one code to fully describe the condition, circumstance, or manifestation.
When the histological type of neoplasm is documented, reference the Alphabetical Index first rather than going immediately to the Neoplasm Table.
SIRS is the diagnosis, when all of the following are diagnosed: hypothermia or fever
increased or decreased WBC.
Viral hepatitis codes are divided based on the type of hepatitis and if the condition is with or without hepatic coma.
When an encounter is for treatment of anemia due to a malagnancy, the first-listed diagnosis would be the malignancy, followed by the anemia.
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