An Institute of Medical Coding guide to understanding how accurate documentation supports sound coding decisions.
The first-listed condition
The reason chiefly responsible for an encounter can determine the first-listed diagnosis, but terminology and rules differ across outpatient and inpatient settings. Coders must apply the guidelines for the relevant setting and code set.
Additional conditions
Other documented conditions may also be reportable when they meet the relevant criteria. A long problem list alone does not mean every item belongs on a particular claim. Review what was evaluated, treated or affected care under applicable rules.
Instructions can determine order
Code-set conventions, combination codes, manifestation instructions and encounter-specific guidance may affect sequencing. Read the tabular notes and official guidance before deciding that the clinically most dramatic condition always comes first.
A simple method
Identify the setting and date, read the final documentation, list supported conditions, verify codes and then apply the relevant sequencing instructions. Record the reason for the order so a reviewer can follow the decision.
