Coding a Visit From the Note

In practice

In a practice where medical assistants help prepare claims for review, a provider's note reads: "Cough and fever for three days. Possible pneumonia; chest X-ray ordered. Type two diabetes, controlled, considered in choosing treatment. History of appendectomy." The medical assistant works through it using the guidelines. Pneumonia is documented as possible, so she does not code pneumonia. Instead she codes to the highest degree of certainty: the cough and the fever, which are the reason for the visit, listed first. The diabetes is a coexisting condition that affected treatment, so it is coded as well. The appendectomy was in the past and is no longer being treated, so it is not coded as a current condition. For each code, she finds the term in the Alphabetic Index, verifies it in the Tabular List, and reads the notes in both. She checks that every code has its full number of characters. When the X-ray result comes back and the provider documents a confirmed diagnosis at a later visit, that visit will be coded with the confirmed condition. She submits the prepared codes to the provider and the billing staff for review, following the practice's process.