S19

Clinical notes

Documentation support

General coding-documentation guidance — not a substitute for payer-specific requirements or professional coding judgment.

• •This is a non-billable header code. Documentation must support a more specific child code before this diagnosis can be reported on a claim.
• •This code describes an unspecified presentation. If the medical record documents a more specific detail (e.g. laterality, type, or affected site), a more specific sibling code should be used instead — see Related codes below.
• •This category requires a 7th character. Documentation should clearly indicate the episode of care (initial encounter, subsequent encounter, or sequela).
• •As a general rule, code to the highest level of specificity supported by the documentation in the medical record.