Documentation and coding for trauma and surgical critical care: updates and tips

Abstract

Clinical documentation is an essential part of medical practice. Medical records serve as a durable testament of care provided and are fundamental to communication among providers. Medical records provide justification and support for healthcare coding and billing for providers and hospitals and also provide evidence in regulatory and legal proceedings. Here, the authors emphasize the importance of clinical documentation in support of both professional and hospital billing and address two areas of recent regulatory changes: Operative coding for hernia operation and professional coding for critical care. The important role of provider documentation in supporting organizational revenue and quality is also discussed.