E/M Coding Alert - 2015 Issue 10
Reader Question: Distinguish Chronic, Acute in Medical Record
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Article Overview
This reader Q&A addresses a common documentation challenge in medical coding: determining how to handle records that do not clearly state whether a condition is acute, chronic, unspecified, or a combination of those states. It compares ICD-9 and ICD-10 approaches using cholecystitis as the example and discusses related tabular-list considerations and general sequencing guidance. The article is relevant to coders and auditors who need a practical understanding of how documentation specificity affects code selection.
Why This Topic Matters
Accurate interpretation of vague documentation affects code selection, specificity, and consistency across ICD-9 and ICD-10. This topic is important for coding professionals, auditors, and compliance staff working with incomplete or nonspecific physician documentation.
What You Will Learn
- How nonspecific documentation is typically handled when a condition can be coded as acute, chronic, unspecified, or both.
- How the article compares ICD-9 and ICD-10 using cholecystitis as the example condition.
- How tabular-list terminology can affect interpretation of documentation.
- What the article says about situations where no unspecified option is available.
- How the article frames general sequencing when both acute and chronic conditions are documented.
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Documentation improvement professionals
- Billing and reimbursement professionals
Codes Discussed
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