Reader Questions: Don't Let Shorthand Block You From Correct Code

Article Overview

This article addresses a reader-submitted emergency department coding question involving a shorthand entry in the medical record and the need to clarify documentation before claim submission. It is relevant to emergency department coders, billers, and clinicians who document or review procedure notes, and it focuses on the general process of interpreting abbreviated chart language, associating the documented condition with the encounter, and selecting the appropriate procedure and diagnosis code categories.