Diagnosis coding demonstrates the medical necessity for the services rendered to your patients. And, since enactment of the Affordable Care Act (ACA) and subsequent increasing significance in demonstrating quality of care, diagnosis coding is ever more crucial. On the date of the patient encounter, (follow these steps) for best coding practices:
1. Code and document to the highest degree of knowledge.
2. Include, document and code relevant co-morbidities and issues in patient progress notes.
3. Prioritize diagnoses codes in order of acuity.
4. Reflect and document laterality.
5. Without a definitive diagnosis, code signs and symptoms; document rule outs; possible and probable in patient progress notes.
6. And, maintain a “frequently diagnosed” list, whether on paper or in an Electronic Health Care Record system, and avoid spending time on searching for correct diagnoses codes.
As Medicare and Medicaid advantage programs implement Hierarchical Condition Coding for provider reimbursement, diagnoses coding will increasingly affect and reflect reimbursement for a patient’s acute and chronic illnesses.