Reader Questions: Make Sure the Documentation Tells the Story

Why This Topic Matters

Accurate coding depends on complete documentation, especially when visit level, timing, and diagnosis specificity all affect code selection. This article helps readers recognize which missing elements must be clarified before coding a concussion-related office visit.

Article Sections

1. Question

   Presents the coding scenario and the documentation issue that prompted the question.

2. Answer

   Explains that the record is not complete enough for coding and identifies the broad documentation elements that must be confirmed.

3. E/M coding

   Discusses office visit coding considerations for new versus established patients and how the encounter information affects selection of the E/M level.

4. ICD-10 coding, step 1

   Reviews the broad concussion diagnosis categories that depend on additional clinical detail in the documentation.

5. ICD-10 coding, step 2

   Addresses the encounter-stage character used with the concussion diagnosis code in different visit contexts.