AHA Coding Clinic® for ICD-9 - 2011 Issue 1; Ask the Editor
Code Assignment Based on Up and Down Arrows
Is it appropriate to assign a diagnosis code for a condition listed with up and down arrows? For example, the provider documents ↑ cholesterol, or ↑ lipids, or ↓ hemoglobin and hematocrit—should a code be assigned for hypercholesterolemia, or hyperlipidemia, or low H&H, etc.? Does the advice change depending on whether this is an outpatient encounter versus an inpatient admission? ...
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Article Overview
This article addresses a common documentation question in medical coding: whether diagnosis codes should be assigned when a provider notes trends using up or down arrows. It explains the documentation issue in general terms, discusses why clarification may be needed, and notes that the question can arise in both outpatient and inpatient settings. The article is aimed at coders, billers, and other healthcare staff responsible for accurate diagnosis reporting.
Why This Topic Matters
Trend symbols in clinical documentation can be ambiguous, so understanding how to respond helps reduce inaccurate diagnosis reporting and supports cleaner documentation workflows across care settings.
What You Will Learn
- How to evaluate diagnosis documentation that uses trend symbols instead of explicit terms
- Why provider clarification may be necessary when documentation is ambiguous
- How the issue may arise in outpatient and inpatient encounters
- The role of the provider versus the coder in documenting a diagnosis
Who Should Read This
- Medical coders
- Medical billers
- Clinical documentation staff
- Healthcare compliance staff
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