Health Information Management

Maintain compliance when coding from the medical record

Briefings on Coding Compliance Strategies, March 1, 2008

You might think that everything between the first and last page of a medical record is fair game when it comes to code assignment. But in most cases, physician entries are the only appropriate sources from which to garner diagnosis codes. The discharge summary is the most reliable part of the medical record because it is the physician's final account of his or her patient care, says Lori S. McGuire, CCS, EMT, founder of Simply Coding in Nevada, OH. The discharge summary best supports a principal diagnosis that the physician must determine after study.

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