To capture the best clinical diagnosis, providers must document the following aspects of Location:
- Be very specific as to the anatomic locations
- Finger: Phalanges, phalanxes (Proximal, middle and distal phalanx)
- Toe: Individual toes and specific joints
- Hand: Carpal, metacarpals, trapezium, trapezoid etc.
- Foot: Tarsal, metatarsals, joints, intertarsal etc.
- The documentation of laterality is key to accurate code assignment
- Document right, left or bilateral for paired organ structures
- Example: Bilateral pneumonia
- Indicate the geographic location
- Home, work, amusement park, grocery store etc.
- Describe the activity
- Job related, playing football, jumping jacks, Frisbee etc.
- Document right, left or bilateral for paired organ structures
- Think of the board game Clue to help you remember the appropriate documentation of location
- Abrasion of the right ear that occurred at home while bathing the dog in the bathroom of the patient’s mobile home.
- Abrasion of the right ear, initial encounter (S00.411A)
- Struck by the dog, initial encounter (W54.1XXA)
- Bathroom in the patient’s mobile home as placeof occurence (Y92.O22)
- Activity, grooming or shearing an animal (Y93.K3)
- Abrasion of the right ear that occurred at home while bathing the dog in the bathroom of the patient’s mobile home.
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