It depends on who will be reading your notes later on. With a normal claim, you’re writing for a payer’s eyes only. In this case, the notes or flaky coding may be presented in front of a judge, opposing attorney, or jury at a later date, and it could cost you more than the reimbursement. All items should clearly relate the diagnosis to the actual incident. That’s the real challenge behind personal injury billing: You’re not just coding for payment; you’re coding for a legal record that has to hold up under pressure.
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