AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2013 Issue 3; Ask the Editor
Assigning Codes Using Prior Encounters
Is there a guideline or rule that indicates that you should only use the medical record documentation for that specific visit/admission for diagnosis coding purposes? Does each visit or admission stand alone? Would the coder go back to previous encounter records to assist in the coding of a current visit or admission? ...
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Article Overview
This article addresses a common coding question about whether diagnosis coding should rely only on the documentation from the current visit or admission, or whether prior encounter records may be reviewed for context. It is aimed at coders and billing professionals working with outpatient and inpatient records, and it focuses on documentation relevance, encounter-specific reporting, and the role of the physician in identifying conditions tied to the current service.
Why This Topic Matters
Accurate diagnosis coding depends on understanding what documentation is relevant to the encounter being reported. This topic matters because it affects how coders interpret current and historical information while staying aligned with encounter-specific recordkeeping requirements.
What You Will Learn
- How current-encounter documentation relates to diagnosis coding
- Why historical information may not always apply to a new encounter
- The physician’s role in identifying conditions relevant to the current visit
- How recurring conditions are considered in the context of an encounter
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Health information management professionals
- Physicians
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