How should you code each encounter?

• A. Code only the first listed symptom.
• B. Code to the level of certainty known for that encounter.
• C. Code to the most likely diagnosis regardless of certainty.
• D. Code only after discharge.

Answer: (B)

You should code to the level of certainty documented for that encounter. The codes you assign must reflect what the clinician actually concluded or reasonably documented at that visit. If the record shows a definite diagnosis, code that diagnosis. If the clinician lists a probable or rule-out diagnosis, code the level of certainty present in the documentation (or code the signs and symptoms if no diagnosis is documented). Do not code the first symptom alone or assume the most likely diagnosis without documentation. Coding is based on the encounter’s documentation and is not tied to a discharge timing; it should reflect what was known at the time of the encounter and be updated if the final diagnosis becomes clear later.