What does the term assumption coding mean?
A) The medical coder was using diagnosis codes that are not as specific as possible.
B) The medical coder coded and reported services that were not documented in the patient's medical record.
C) The medical coder coded and reported services that were documented in the patient's medical record.
D) The medical coder has a mismatch between the gender of the patient and the selected code.

Question

Quizplus · Accepted Answer

Assumption coding refers to the practice where a medical coder codes and reports services that were not actually documented in the patient's medical record, often based on assumptions rather than concrete evidence. This is considered a coding error and can lead to inaccurate billing and potential compliance issues.

What Does the Term Assumption Coding Mean