• Overview of coding principles
  • Condensed Coding Table 1
  • Section Elements: Rules for table building
• Coding Documentation Template (CDT) – with text boxes
• Master list (Principles)
• Coding Documentation Template (BASIC)
• Coding Documentation Template (with Auto-Complete)
• Coding Documentation Template (v1) depreacted
• Coding Documentation Template (v2)

Rules & Key Elements for Each Section

Principal Diagnosis (PD)

• What coders look for:
  • ONE condition clearly stated as the reason for admission.
  • Cannot be a symptom or event (unless no diagnosis found).
  • If uncertain: use probable, likely, presumed.
• Mandatory Field:
  • Principal Diagnosis: ____________________________

Linked Cause (If Applicable)

• Why: Improves coding weight (e.g., Anaemia due to blood loss).
• Mandatory Field:
  • Cause of PD: ____________________________

Secondary Diagnoses

• What coders look for:
  • Conditions requiring treatment, monitoring, tests, or adding resource use.
  • Must show linkage to clinical care.
• Mandatory Field:
  • Other Significant Diagnoses: ____________________________

Procedures

• What coders look for:
  • Any therapeutic or diagnostic procedure affecting care.
• Mandatory Field:
  • Significant Procedures: ____________________________

Specificity Requirements

(These add coding weight, so missing detail costs money.)

• Fractures: Site, laterality, open/closed, stage of healing.
• Pressure Injuries: Stage 1–4.
• Infections: Organism if known.
• Anaemia: Acute/chronic and cause.
• AF: Was it treated?
• Mandatory Fields:
  • Fracture Details: Site ___ Laterality ___ Open/Closed ___
  • Pressure Injury: Stage ___
  • Infection Details: Organism ___ Source ___
  • Anaemia Details: Acute/Chronic ___ Cause ___

Clinical Significance of Abnormal Tests

• Coders ignore raw results. They need interpretation and action taken.
• Mandatory Field:
  • Abnormal Results Addressed: ____________________________