Question

what is the one absloute rule of a professional coding specialist concerning documentation

Answer 1

One absolute rule of a professional coding specialist concerning documentation is that the diagnosis or procedure codes needs to be coded with the highest specificity/accuracy level with the correct modifiers. Each diagnosis or procedure code should be specific and accurate so that there will be no confusion for the insurance companies about the exact diagnosis of the patient. Absolute highest specificity level is needed for each code by following the coding guidelines to avoid further inaccuracies in patient’s treatment, payment, insurance, etc. Specificity and accuracy in coding ensures the accuracy patient’s treatment as well as billing and reimbursement of the facility or physician. Inaccurate coding could directly affect a patient’s treatment resulting in a negative impact on the facility. Inaccurate coding using wrong modifiers could also lead to improper patient treatment at another facility. Thus the significance of specific, accurate, and complete coding continues to increase and points to the accuracy in clinical documentation, a must have for accuracy in coding.