Abstracting from the EHR

1. Understand the Purpose: Before starting, ensure clarity on the purpose of coding. Are you coding for reimbursement, research, or statistical analysis? Each purpose may require a slightly different approach or level of detail.
2. Review Entire Medical Record: Begin by reviewing the entire medical record thoroughly. This includes admission notes, progress notes, physician orders, consultation reports, diagnostic test results, operative reports, discharge summaries, and any other relevant documents.
3. Identify Key Elements: Pay close attention to key elements that impact coding, including:
   • Patient demographics: Ensure accuracy in patient identifiers, such as name, date of birth, and medical record number.
   • Dates of service: Note the dates of admission, discharge, and any relevant procedures.
   • Chief complaint: Understand the primary reason for the patient’s encounter.
   • History of present illness (HPI): Document the patient’s symptoms, their duration, severity, and any associated factors.
   • Past medical history (PMH): Note any significant past illnesses, surgeries, or medical conditions.
   • Review of systems (ROS): Record findings from the review of various body systems.
   • Physical examination: Document pertinent positive and negative findings from the physical examination.
   • Diagnostic tests and results: Include laboratory test results, imaging studies, pathology reports, and any other diagnostic findings.
   • Procedures performed: Detail any surgical procedures, interventions, or other treatments performed.
   • Discharge summary: Summarize the patient’s course of treatment, final diagnosis, procedures performed, and recommendations for follow-up care.
4. Code Assignment: Translate the abstracted clinical information into appropriate diagnosis and procedure codes using standard code sets such as ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) for diagnoses and CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) for procedures.
5. Follow Coding Guidelines: Adhere to official coding guidelines and conventions provided by organizations such as the Centers for Medicare and Medicaid Services (CMS) or the American Hospital Association (AHA). Ensure accurate code selection based on specificity, documentation requirements, and any applicable coding rules.
6. Document Findings: Maintain clear documentation of the abstracted information and code assignments for auditing, compliance, and reference purposes. Ensure confidentiality and security of patient health information (PHI) in accordance with HIPAA regulations.
7. Continuous Education: Stay updated with changes in coding guidelines, regulations, and technology advancements through ongoing education and professional development activities. Regularly review coding resources, attend workshops, and participate in relevant training programs to enhance coding proficiency and accuracy.

By following a systematic approach and exercising attention to detail, medical coders can effectively abstract information from medical records for coding purposes, ensuring accurate and compliant coding practices.

Step 1: Review the Registration page. It contains patient identification information, insurance data, and clinical data such as admitting and final diagnosis. Take special note of the patient’s gender, age, length of stay, and anything that relates to the complexity of the diagnosis and treatment.

Step 2: Review the content of the medical record: Physical examination (PE) History of Present Illness (HPI) Chief Complaint (CC) Review Of Systems (ROI) Personal, Family, and Social History (PFSH) Emergency department and consult reports Principal Diagnosis- Review this information to determine the provider’s principal diagnosis which is the condition after study chiefly responsible for the patient’s admission and any secondary diagnoses or other diagnoses that may affect the patients care such as complications and or comorbidities that the patient received treatment. Preoperative and Postoperative Diagnosis Treatment Plan Principal Procedures- Review this information to determine the providers’ principal procedure which can be diagnostic, therapeutic or to treat a complication. It is the procedure to be determined to be most closely related to the principal diagnosis.

Step 3: Review all reports: Operative procedures Special procedures- Cardiac catheterization, upper and lower endoscopies, bronchoscopies with or without biopsies. Anesthesia Pathology Special consents Note: Remember to sequence definitive before diagnostic procedure codes.

Step 4: Progress notes: Includes- admit note, notes related to the patient’s condition and progress, responses to treatments, and a discharge note. Note any significant findings and resolutions of problems or complications.

Step 5: Review all tests: Laboratory- Chemical, analyses, cultures, body fluids (blood, urine, stool, and pus) Radiology- x-rays-Computerized Tomographic scan (CT), Nuclear Medicine studies, Magnetic Resonance Imaging (MRI), Arteriograms, etc. Special tests-Electrocardiogram, echocardiogram, Cardiac stress test, etc. Abnormal findings

Step 6: Review provider orders: Determine the treatment for the patient and directions to the nursing staff and ancillary personnel that direct all treatments and medications to the patient.

Step 7: Review Medication Administration Record (MAR): Provides documentation of drugs given to the patient to help support the diagnosis- drug names, dosages, times given, and routes of administration (Mouth, injection, intramuscular or intravenous). Long Term Drugs (LTD)

Step 8: Review Discharge Summary (DS): Summary of the patient’s course in the hospital, condition upon discharge, discharge instructions, and follow-up plan for future treatment. It includes all final diagnoses as well as all procedures.

Step 9: Code assignment: Assign codes by following: Uniform Hospital Discharge Data Set (UHDDS) CPT, ICD-10-CM, ICD-10-PCS and HCPCS Code sets- using each code set conventions, guidelines, and sequencing rules. Remember to code to the most specific codes. Remember Medicare and or specific payer guidelines/rules for your provider and other payers.

     8 Steps to Code:

1. Identify the main term(s) and sub-term (s) for procedures, tests, services, equipment, and supplies from the medical record.
2. Locate the main term(s) in the Alphabetic Index by service or procedure, anatomic site, condition or disease, synonym, eponym, or abbreviation.
3. Review any subterm (s) under the main term in the index.
4. Follow any cross-reference instructions such as SEE
5. Verify the chosen code in the Tabular list for further coding specifics such as code first or code additional. (Never code directly from the Index alone as you may miss important things that may lead you to choose a more specific code choice).
6. Refer to any Tabular list of instructional notations such as conventions, notes, and related guidelines.
7.  Assign codes to the most specific code choice (CPT may require a modifier and both CPT and ICD-10-CM may require an unlisted or unspecified code choice).
8.  Code all diagnoses, procedures, supplies, tests, services, and equipment until all elements are completely identified.
9. General Reporting Requirements

• POA indicator reporting is mandatory for all claims involving inpatient admissions to general acute care hospitals or other facilities.
• POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.
• A POA Indicator must be assigned to principal and secondary diagnoses and the external cause of injury codes. CMS does not require a POA Indicator for an external cause of injury code unless it is being reported as an “other diagnosis.”
• If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then the POA Indicator would not be reported.

1. Selection of Principal and Secondary Diagnosis(es)

• The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
• The UHDDS definitions are used by hospitals and includes all non-outpatient settings (acute care, short-term, long-term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc.). The UHDDS definitions also apply to hospice services (all levels of care).
• Coding conventions in the ICD-10-CM, the Tabular List and Alphabetic Index take precedence over these official coding guidelines.
• Symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established.
• When there are two or more interrelated conditions (such as diseases in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.
• When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first
• When two or more diagnosis equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided and the Alphabetic Index and/or Tabular list or other coding guideline does not provide sequencing direction then either diagnosis may be sequenced first. If one of the diagnosis results in extensive or nonextensive O.R. procedure unrelated to the principal diagnosis MS-DRGs 981-989), the diagnosis that does not result in the unrelated DRG would be principal diagnosis.
• The Medicare Claims Processing Manual Chapter 3 states that in order to appropriately identify the severity of the patient and the resources utilized, sequence the principal diagnosis, the condition that results in the higher relative weighted assignment.
• Additional diagnosis as defined by the UHDDS as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay and diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.
• UHDDS defines all significant procedures are to be reported. A significant procedure is defined as surgical in nature, carries a procedural risk or carries an anesthetic risk or requires specialized training.
• The principal procedure is defined by the ICD-10-CM guidelines as the procedure that is most directly related to the principal diagnosis.
• It is the coders responsibility to determine what the documentation in the medical record equates to in the ICD-10-PCS manual definitions.
• Areas of the medical record that contain acceptable physician documentation to support code assignment include the discharge summary, current history and physical, ER record, physician progress notes, physician orders, physician consultations, operative reports, anesthesia notes, and physician notations of intra-operative occurrences.
• Diagnoses in other documentation such as but not limited to nurse notes, EKGs, nutritional evaluations, pathology–radiology–lab, and other ancillary reports not documented by the provider directly participating in the care of the patient must be queried for confirmation of the condition except for BMI or pressure ulcer stages can be provided by clinicians. Use the documentation of these to confirm things such as sites and locations.
• In inpatient admissions any diagnosis documented at the time of discharge is qualified as probable, suspected, likely, questionable, possible, still to be ruled out, compatible with, consistent with or other similar terms indicating uncertainty, code the condition as if it existed or was established.

Step 10: Always: Remember the conventions, guidelines, and sequencing rules. Make sure the documentation supports your coding. Remember the coder’s motto, “If it is not documented it was not done.” If the documentation is not supporting the diagnoses, you may need to query the provider to clarify a diagnosis or to add supporting documentation through a provider added addendum to the record to support the diagnosis intended and codes chosen in case the provider is ever audited as diagnosis codes establish the medical necessity for services and reimbursement.