HCPro, JustCoding Inpatient - 2015 Issue 47 (December)
Q&A: Coding from ED documentation and test results
December 16th, 2015
Subscribe or sign in to view the full article.
Article Overview
This short guidance article explains a documentation-focused coding question for emergency department encounters and related test or imaging reports. It is aimed at coders, CDI professionals, and other coding staff who need to understand the broad boundaries of provider documentation used for diagnosis assignment and when clarification may be needed. The article also notes the relationship to ICD-10-CM/PCS guidance and references professional education sources.
Why This Topic Matters
Healthcare coding decisions depend on the right source documentation. Understanding which provider notes can support diagnosis coding, and how to handle test or radiology reports at a high level, helps coding teams review records consistently and know when to seek clarification.
What You Will Learn
- Which types of provider documentation may support diagnosis coding in an ED encounter.
- How test results and imaging reports are treated in relation to diagnosis assignment.
- When documentation review may require clarification from a provider.
- How the article relates broadly to ICD-10-CM/PCS guidance and CDI practice.
Who Should Read This
- Medical coders
- CDI specialists
- Coding auditors
- Inpatient and emergency department coding staff
- Clinical documentation review teams
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com