If there is unclear information in the documentation, the coder should:
A) code the diagnosis as though it existed.
B) not code the diagnosis.
C) query the physician.
D) give the chart to the coding supervisor to code.

Question

Quizplus · Accepted Answer

When there is unclear information in the documentation, the coder should query the physician for clarification. This ensures accurate coding and prevents potential errors or inaccuracies. Coding the diagnosis as though it existed or not coding it at all may lead to incorrect billing or missed opportunities for reimbursement. Giving the chart to the coding supervisor to code may also delay the coding process and the necessary clarification should be obtained as soon as possible.

If There Is Unclear Information in the Documentation, the Coder