#Diagnosis code for atrial fibrillation code#
#Diagnosis code for atrial fibrillation professional#

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. Each healthcare encounter should be coded to the level of certainty known for that encounter. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. The ICD-10-CM Coding Guidelines contain an entire chapter (chapter 18) which includes, “Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99).”

#Diagnosis code for atrial fibrillation code#

Therefore, in the setting of the Emergency Department it is very important to document and code signs and symptoms. While this is true, it is not always possible to know the diagnosis. What coding to use in the Emergency DepartmentĪs it pertains to clinical documentation and the use of ICD-10-CM codes, it is widely known that one should select the most specific and accurate diagnosis code.

#Diagnosis code for atrial fibrillation professional#

Medical necessity must be established when documenting any professional medical encounter. In terms of documentation and coding the presenting symptoms establish medical necessity. Clinically the initial presenting symptoms are extremely important, as they impact triage, immediate treatment, stat orders, possible need for a specialist consultation and more. Some providers may be shocked to learn of the significance of documenting the chief complaint (also known as reason for the visit). When we think of any professional medical evaluation, it all starts with presenting symptoms. It is best to ponder the basics of excellent documentation in answering that question. So, one might ask themselves how this impacts documentation and coding in the emergency department. The Emergency Department is complex in so many ways it is like an amalgam, part outpatient encounter, part hospital encounter.

Clinical Documentation and Coding in the Emergency Department