Rely On Physician's Notes When Selecting Dx Codes

Article Overview

This article explains how emergency department coders may review physician notes, chart details, and supporting documentation to identify the appropriate diagnosis coding when the stated diagnosis is incomplete, unclear, or absent. It is aimed at coders, billing staff, and practice managers who work with ED documentation and internal coding policies. The article also covers the need for written procedures, communication with physicians when needed, and the role of documentation review in supporting accurate claim submission.