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Sample Query: Signs and Symptoms
Signs or symptoms of an underlying condition should be coded only if the physician can not determine a definitive diagnosis. When the physician simply neglects or forgets to document the diagnosis, CDI staff can use this sample query template provided by Alesha Andrews, RHIT, CCS, and Adam Norbeck of St. Rita's Medical Center in Lima, OH, to help remind physicians that more than symptoms are needed to accurately reflect the care provided to the patient.
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