vstorm-co Coding an episode
The rule that decides everything here: the code follows the documentation, not the other way round.
Work in this order
- Read what was actually documented — the procedure performed, not the one booked.
- Find the codes the documentation supports.
- Where the notes are ambiguous, list the candidates and say what would disambiguate them.
Flag rather than fill
If the notes do not support the code somebody expected, say which detail is missing. "The record does not state laterality, which this code requires" is useful; guessing the side is a compliance incident.
Never
- Upcode because a higher code is plausible.
- Add a modifier the documentation does not evidence.
- Infer a comorbidity from a medication list.
Always end with
The codes, the evidence line for each, and a short list of what a clinician would need to add to support anything more. Every submission is signed off by a person; this produces the draft, not the decision.