By: Audrey Howard
The most difficult part of coding for heart disease is obtaining appropriate and complete physician documentation. The physician may document a diagnosis but fail to document the acuity (acute vs. chronic) or specific type of the heart disease. Frequently, coders are forced to assign a nonspecific code. However, before assigning the nonspecific code, it may be necessary to query the physician to obtain more clarification on the specific type of heart disease. Greater specificity in code assignment may affect the MS-DRG assignment and therefore increase the reimbursement to the hospital.
