Coding from Diagnosis List
I have reviewed previous threads for this topic, but could only find discussions related to problem lists, so here goes...
Our diagnosis list (Cerner) populates based on IMO terminology with an "annotated display" and a "clinical diagnosis display". Often, the annotated display is abbreviated, lacking specificity that is found in the clinical diagnosis display.
My feeling is that the diagnosis list is being managed for the specific, current encounter and therefore, as part of the medical record, can be utilized in its entirety for coding purposes/obtaining specificity. Coders generally will not code from the clinical diagnosis list because only the annotated display terminology populates the progress notes.
Any thoughts/insights/wisdom on this topic are greatly appreciated!!
Thanks in advance,
Jackie Touch, MSN, RN, CCM
Clinical Documentation Specialist
CHOC Children's
Our diagnosis list (Cerner) populates based on IMO terminology with an "annotated display" and a "clinical diagnosis display". Often, the annotated display is abbreviated, lacking specificity that is found in the clinical diagnosis display.
My feeling is that the diagnosis list is being managed for the specific, current encounter and therefore, as part of the medical record, can be utilized in its entirety for coding purposes/obtaining specificity. Coders generally will not code from the clinical diagnosis list because only the annotated display terminology populates the progress notes.
Any thoughts/insights/wisdom on this topic are greatly appreciated!!
Thanks in advance,
Jackie Touch, MSN, RN, CCM
Clinical Documentation Specialist
CHOC Children's
Comments
Off my soapbox now...thanks for letting me vent.
Jackie