Coding from header

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I know its the golden rule to not code from an electronic header, but is there something in writing that outlines this rule?
 

Pam Brooks

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Local Chapter Officer
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If only we had black and white rules! I don't know of any specific regulatory guidance that says 'don't code from the header', but the guidance does tell us that all coding--procedural and diagnostic both---are to be assigned based on the physician documentation. So if the header tells us laparoscopic cholecystectomy, and the surgeon converts to open--the explanation of which is found in the body of the note.....well there's the answer.
 

Venkatakrishnan

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Yes I agree with Pam. It is always good (even right) to code based on the detail description of the procedure since the header documentation will give you information just about the procedure whereas the detailed description gives you the whole picture and also it guides you on any alteration (both more than planned or less than planned) of services provided.

As Pam said, any conversion of approach in cholecystectomy cases (Laparoscopic to Open) or additional services during cholecystectomy ( "with cholangiogram" ) or Vaginal hysterectomy (with documentation of weight of the uterus and information on tube removal) or approach in myomectomy cases (vaginal / abdominal), Level of toe amputation (Interphalangeal vs Metatarsophalangeal) or Complexity of the abscess drainage (simple vs complex) etc....

Additionally, we can collect some diagnosis information from the body of the report.

So, when we have many benefit of detailed notes, why should we miss them out?

Thanks,
Vernon Kreiss
 
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