AHA Coding Clinic® for ICD-9 - 2005 Issue 3; Ask the Editor
Coding and Physician Orders
A patient with several chronic debilitating conditions is admitted to a long-term care facility. The physician makes a telephone order for anti-depressive medication. There is no mention of depression in the health record documentation. Would it be appropriate to assign a code for depression based on the phone order for antidepressants? ...
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Article Overview
This article explains a documentation-focused coding scenario involving physician orders in a long-term care setting. It is aimed at coding professionals and clinical documentation staff who need to understand when an order alone is not enough to support diagnosis coding and why physician clarification matters.
Why This Topic Matters
Accurate diagnosis coding depends on documented clinical support, not on medication orders by themselves. The article highlights the importance of physician clarification and record amendment when documentation is incomplete.
What You Will Learn
- How physician orders are treated in relation to diagnosis documentation
- Why supporting documentation matters before assigning a diagnosis code
- When physician clarification and record amendment may be needed for incomplete documentation
- Documentation considerations in a long-term care admission scenario
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement staff
- Long-term care documentation personnel
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