Health Information Management

Tip of the week: Consider these seven steps to accurate coding

HIM-HIPAA Insider, November 27, 2007

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Use the following seven-step checklist to code encounters correctly:

  1. Read the entire superbill and all physician's notes for the encounter.
  2. Reread the physician's notes. Make a copy of the notes and superbill relevant to the patient's visit so you can write on them without marking the originals (you can also use scratch paper). Highlight words that are important to your selection of diagnosis and procedure codes.
  3. Query or confer with the healthcare provider regarding any unclear, inconsistent, or missing information. Never assume or guess. Code only what you know from actual documentation. If the physician did not document it, you cannot code it.
  4. Code each confirmed diagnosis and/or the appropriate signs or symptoms describing why the healthcare professional provided the services reported for this encounter, in accordance with the physician's notes. Use the most specific code available based on the documentation.
  5. Code each procedure, service, and treatment that the physician and staff provide, in accordance with documentation.
  6. Verify medical necessity by linking each procedure code to at least one diagnosis code on the same claim.
  7. Double-check your codes. Reread the descriptions of the codes you assigned and match them with the notes to double check your code assignment.

Editor's note: This tip is adapted from an article in For more information, click here.

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