Question

multiple select question

select all that apply

coding diagnoses are based on the providers diagnosis or diagnoses. this information may be located in which of the following documents?

claim form
progress notes
encounter form
patients statement

Explanation:

Identify source documents for coding

Medical coding requires official clinical documentation completed by the healthcare provider to support the assigned diagnosis codes. We must evaluate which of the listed documents contain the provider's actual diagnosis or diagnoses.

Evaluate progress notes

Progress Reports (or progress notes) are written by the healthcare provider during or after a patient encounter. They contain clinical details, assessments, and the provider's official diagnoses. Therefore, progress notes are a primary source document for coding.

Evaluate encounter forms

An Encounter Form Documentation (also known as a superbill) is completed by the provider during the visit. It contains a list of common diagnoses and procedures, where the provider checks off the specific diagnoses established during the encounter. Thus, it is a valid source.

Evaluate claim forms and patient statements

A claim form is the end product of the billing process generated from the coded documentation, not the source document where the provider's original diagnosis is located. A patient's statement contains subjective complaints or financial billing details, not the provider's official clinical diagnosis.

Answer:

• claim form
• progress notes (Correct answer)
• encounter form (Correct answer)
• patient's statement