Clinical Language and Coding Rules

Provider documentation must be precise to avoid missing valid diagnoses.

Ineffective Documentation:

• Problem list cannot be used for coding [unless brought into the assessment and plan]
• Differential diagnoses cannot be used by coding
• Documenting “empirical treatment” is ineffective documentation
  • Pneumonia will not be coded if “empirically treating pneumonia” is documented

Effective Documentation:

• Uncertain diagnoses can be coded if the condition remains uncertain at the time of discharge
  • Documented as “suspected, likely, probable, consistent with, or compatible with” in the discharge summary will allow coding to capture
    • “Suspected acute tubular necrosis”
      • Will code to ATN if documented on the DC summary

Best Practice Documentation:

• Clinical diagnoses can be captured using “evidence of” when a diagnosis is supported by the patient’s clinical picture, symptomology and response to treatment.
  • “Evidence of”
    • Coding rules treat as a confirmed diagnosis
    • Providers are encouraged to use the phrase “evidence of” when making a clinical diagnosis or when the etiology cannot be definitively established
      • “Evidence of sepsis”
        • Will code to sepsis
      • “Evidence of pseudomonas pneumonia, therefore, will treat with Zosyn”
        • Will code to pseudomonas pneumonia
      • “Evidence of stroke, therefore, will consult Neurology”
        • Will code to stroke

Download the complete tip, Clinical Language and Coding Rules.