AHA Coding Clinic® for ICD-9 - 2005 Issue 3; Ask the Editor
Coding and Physician Orders
A new resident of a long-term care facility is prescribed ativan. In the order the physician documents, “DX: Anxiety.†Would it be appropriate to code anxiety based upon the documentation of this diagnosis in the physician order? ...
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Article Overview
This article discusses the relationship between physician orders and diagnosis coding in a long-term care setting. It is aimed at coders and billing professionals who review provider documentation and need to understand when a diagnosis noted in an order may be considered part of the record, along with when clarification from the physician may be appropriate.
Why This Topic Matters
Accurate diagnosis coding depends on recognizing which parts of the medical record support the reported condition. This topic matters because physician orders may affect coding decisions and documentation review workflows in long-term care.
What You Will Learn
- How physician orders fit into documentation review for diagnosis coding
- When a diagnosis noted by a physician may be considered for coding
- Why clarification from the physician may be needed if documentation is uncertain
- How this issue applies in a long-term care facility context
Who Should Read This
- Medical coders
- Billing staff
- Health information management professionals
- Long-term care documentation reviewers
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