My last article on what separates great coders from average coders got a lot of responses. Several of you asked me to share exactly how I personally read an inpatient record. So here it is.
One pass. Every document read once. No going back. This is my standard in production coding and on the CCS exam.
Start with the Emergency Department note.
This tells you why the patient came in. The chief complaint, presenting signs and symptoms, and the clinical concern that triggered the admission. This is your foundation for present on admission status. A condition must be present at admission to qualify as the principal diagnosis. If it was not there at the door, it does not lead the code set.
Next is the history and physical.
Do not chase specificity here. Your goal is volume. Capture every active condition, then pull every chronic condition requiring monitoring from the past medical history, such as hypertension, CKD, or COPD. When addressed during the stay, these add weight to the DRG. Every comorbidity that could complicate treatment belongs on your list. Refine codes as you continue reading.
Next read every consultation note.
This is where your codes get precise. The nephrologist documents type 1 diabetes with diabetic nephropathy. The cardiologist documents chronic systolic heart failure. Consultant notes give you the specificity that turns an unspecified code into the correct one. Do not skip any.
Now read the progress notes.
Track what the team actually treated. Watch for bedside procedures, IV therapy, and surgical intervention. Progress notes are also where new conditions surface. Acute kidney injury on day two, a hospital acquired infection, an arrhythmia that triggers a consult. Any of these can become a CC or MCC and shift your DRG. If documented and treated, it belongs in your code set.
Finally, read the discharge summary.
This confirms everything. Final diagnoses, procedures performed, and patient disposition. Use it to validate your list and lock in your sequencing.
Now for the hard part.
Sometimes the record states a condition could be due to UTI, pneumonia, or cholecystitis. The physician has not committed. You cannot assign the diagnosis that yields the highest DRG. That is upcoding. That is fraud.
Follow the treatment instead. The condition managed with IV antibiotics, surgical intervention, or aggressive workup outweighs one treated with oral medication and monitoring only. Treatment intensity tells you what the team believed was driving the admission. Let that guide your principal diagnosis and your DRG will follow the record, not the other way around.
Read once. Code right. Let the DRG follow the record.
Thank you for reading. I wish every one of you success.
Hoang Nguyen, BS, CCS, CCS-P, CIRCC, CCVTC