CODING GUIDELINES
1.Follow all coding principles outline in the “Essentials of Accurate Coding,”
Use all codes necessary to completely code all diseases and procedures, including underlying diseases.
Refer all medical records of patients treated for multiple trauma and patients hospitalized over thirty days to the coding supervisor to verify selection of principal diagnosis before abstracting.
E codes are used whenever appropriate to identify external codes.
2.Consult the following sources to identify all diagnoses and procedures requiring coding and to increase the accuracy and specificity of coding.
Face Sheet-code diagnoses and complications appearing on the face sheet.
Progress Notes-Scan to detect complications and/or secondary diagnoses for which the patient was treated and/or procedures performed.
History and Physical-scan to identify any additional conditions; such as history of cancer or a pacemaker in situ. These conditions should be coded.
Discharge Summary-read if available and compare listed diagnoses with face sheet. Code diagnoses and procedures listed on discharge summary but not specified on face sheet..
Operative Reports-scan to identify additional procedures requiring coding.
Consult previous medical records in patients admitted for follow-up of neoplasm to determine the primary and secondary sites.
X-ray and laboratory-use reports as guides to identify diagnoses (e.g. types of infections) or more detail (e.g. type of fractures).
Physician’s Orders-scan to detect treatment for unlisted diagnoses-the administration of insulin, antibiotics, and sulfonamides may indicate treatment of diabetes, respiratory or urinary infections which should be confirmed by checking other medical record forms.
3.Code incomplete face sheets by reviewing the above items.
Record codes assigned in pencil on the fact sheet.
Request supervisor’s assistance if difficulty is encountered in identifying codable data by scanning record.
Call physician for diagnostic information only if instructed to do so by supervisor.
4.Exercise discretion in coding diagnostic conditions not identified on the face sheet or discharge summary.
Query physician on the deficiency report if the coding question influences Identification of most specific code..
Review all alcohol/drug abuse cases to confirm prior to coding.
5.Process special diagnostic coding situations as follows:
V codes are used to identify encounters for reasons other than illness or injury. V codes are used as principal diagnoses for newborn admissions (V30.0-V37.0), Chemotherapy session (V58.0), Radiotherapy session (V58.1), Removal of fixation devices (V54.0), and Attention to Artificial openings (V55). For inpatient coding, avoid the use of V codes as the principal diagnosis where a diagnosis of a condition can be made.
V codes are used in outpatient coding when a person who is not currently ill obtains health services for a specific purpose, such as, to act as a donor, or when a circumstance influences the person’s health status but is not in itself a current illness or injury. Patients receiving preoperative evaluations receive a code from category V72.8.
Avoid using codes that lack specificity. These vague codes should not be used if it is possible to obtain the information required to assign a more specific code.
Inpatient coding requires that signs and symptoms are coded when a specific diagnosis cannot be made or when the etiology of a sign or symptom is unknown. Do not code symptoms if the etiology is known and the symptom is usually present with a specific disease process. Example: Do not code convulsions with the diagnosis of epilepsy.
Outpatient coding requires that diagnoses documented as “probable, suspected, questionable, rule out or working”, should not be coded. Code the condition for that visit, i.e., signs or symptoms or abnormal test results.
Chronic conditions may be coded as many times as the patient receives treatment.
Code abnormal laboratory tests only when noted on the face sheet by the attending physician.
When there are more diagnoses for a hospitalization, acute conditions take precedence over chronic and at least one comorbid condition or complication should be included in the diagnoses which may be submitted to Medicare. All complications and comorbitities should be reported for calculating severity of illness.
6.Sequence diagnoses and procedures according to the “Guidelines for Sequencing and Designating Principal Diagnosis and Principal Procedure Codes.”
