- Overview of coding principles
- 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)
✅ Core Principles
- Avoid ambiguous abbreviations; spell out terms.
- Document the condition and its impact on patient care to show resource use.
- Ensure daily progress notes and management plans are recorded.
- Only conditions present on admission or during stay that impact care can be coded.
✅ Principal Diagnosis (PD)
Definition: The condition established after investigation as chiefly responsible for occasioning the episode of care.
- Only ONE PD per admission.
- If multiple conditions exist, select:
- The most serious or life-threatening.
- The one requiring the greatest resource use.
- Document PD in order of significance.
- Do NOT code:
- Symptoms alone (unless no definitive diagnosis is made).
- Procedures as PD.
- Events like falls or MVAs (document the injury instead).
- If uncertainty exists, qualifiers like probable, likely, presumed allow coding.
✅ Secondary Diagnoses / Co-Morbidities
- Include conditions that:
- Require treatment, management, or increased monitoring.
- Lead to diagnostic tests or interventions.
- Increase resource use.
- Document linkage between symptoms and underlying conditions.
- Record all chronic conditions impacting care.
- Examples:
- COPD due to smoking
- Chronic renal failure due to polycystic kidney disease
✅ Specificity Requirements
- Fractures: site, laterality, open/closed, stage of healing.
- Pressure injuries: stage 1-4.
- Infections: specify organism if known.
- Anemia: specify acute/chronic and cause.
- Multi-organ failure: list all affected organs.
- Angina: specify type.
- AF: was treatment given?
✅ Procedures
- Identify and document all diagnostic and therapeutic interventions.
- Do not just list “procedure done”—specify what and why.
✅ Medications
- Indicate the condition for which the medication was given.
- Document medication changes and reasons (e.g., hypotension leading to stopping antihypertensives).
✅ Diagnostic Tests
- Abnormal results alone are not a diagnosis—document the clinical significance.
- Record if abnormality was treated or monitored.
✅ Discharge Summary
- Must include complete, accurate PD and significant conditions.
- Complete promptly to aid coding and continuity.
✅ Common Errors to Avoid
- Leaving out link between condition and cause (e.g., “Anemia” vs “Anemia due to blood loss”).
- Using symptoms without underlying cause.
- Recording event instead of condition (e.g., “Fall” vs “Fractured humerus due to fall”).
REVIEW of DOCUMENTATION:
Coders apply rules:
- Just documenting the lab result (e.g., “low K”) → NO code → $0.
- Naming the condition (“hypokalaemia”) → Codeable → Some funding.
- Condition + evidence of clinical management (e.g., “hypokalaemia treated with IV potassium”) → Higher complexity → Higher funding.
This principle applies broadly to all secondary diagnoses. The coding logic is:
Condition named + significance + intervention = maximum DRG weight.
✅ How to Apply This in the Mandatory Table
We can create fields to force clinicians to document the condition AND action taken, for example:
| Condition | Action Taken |
|---|---|
| Hypokalaemia | IV potassium replacement, ECG monitoring |
This logic needs to be built into every field that influences coding (electrolyte disorders, infections, anaemia, etc.).
Process moving forward:
Create modules for text box and later auto-completion data entry
✅ Core Module (Mandatory for All Patients)
- Principal Diagnosis (clear, no abbreviations)
- Linked Cause (if applicable)
- Secondary Diagnoses (with actions taken)
This ensures the fundamental coding elements are always present.
✅ Add-On Sections Based on Case Type
- Infection Module → Organism + Source + Treatment
- Trauma/Fracture Module → Site + Laterality + Open/Closed + Treatment
- Pressure Injury Module → Stage + Treatment
- Anaemia Module → Type + Cause + Management
- Chronic Conditions Module → Tick boxes + specify treatment
- Electrolyte Disorders Module → (e.g., Hypokalaemia) Condition + Intervention
✅ Why?
- Core section is universal for ED and inpatient coding.
- Specialty add-ons load dynamically in an electronic form based on case type (medical vs trauma vs surgical).
- Auto-complete can suggest preferred phrases (e.g., “Hypokalaemia treated with IV potassium and ECG monitoring”).