The seven steps of accurate coding include:
A) coding only documented conditions.
B) coding the problems told to you by the nurse.
C) coding only the chief complaint.
D) coding the patient's history.

Question

Quizplus · Accepted Answer

Accurate coding involves only coding the conditions that are documented in the medical record. This ensures that the codes accurately reflect the patient's health status and the services provided. Coding should never be based on assumptions or information provided by someone other than the healthcare provider documenting the patient's care. While the patient's history may be a factor in coding decisions, it should never be the only consideration. Similarly, the chief complaint alone may not provide enough information for accurate coding.

The Seven Steps of Accurate Coding Include