Do you capture Descriptive documentation?

ksaalmullerksaalmuller
in Clinical & Coding

Hi All,

We have found conflicting information and it seems to be a topic of debate. What do your departments do with descriptive documentation? Ex: Encephalopathic vs Encephalopathy, Hypotensive vs Hypotension. Do you capture the associated codes, or query for clarification, and in the case of encephalopathy, the specificity?

Thanks!

Kim Saalmuller, RN, MSN, CCDS

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