Clinical Language and Coding Rules

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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

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