Coding professionals may inappropriately assign codes from parts of the medical record where the doctors, early in the workup of a complex patient, were describing differential diagnoses in their evaluation of the patient. Robert S. Gold, MD, discusses whether coders should report every diagnosis mentioned in a patient’s chart.
Physicians use a lot of shortcuts and abbreviations. Some of them may even make it to the official abbreviation list at a hospital. Some don't. Even if they do, some physicians will use the wrong term.