Question

One day, an employee was coding an inpatient record at City Hospital. The physician's documentation was not clear on a high acuity patient; therefore, the employee needed to query the physician for clarification. The employee knew the answer to her question and was tempted to bypass querying the provider and just code the patient's record based on what she knew. She was tired of all the querying!

1. Should the employee query the provider?

2. Is it acceptable for the employee to code the patient record since she knew the answer, and didn't want to bother with the query?

3. What repercussions might there be if she doesn't query and the medical record doesn't support her coding logic?

Answer 1

1. Should the employee query the provider?

When in doubt, coders should hold the record until receiving confirmation from the physician , so that it does not conflict with the final coded.

2. Is it acceptable for the employee to code the patient record since she knew the answer, and didn't want to bother with the query?

No it is not acceptable because

Medical documentation requires a concerted effort from a variety of patient care stakeholders.

The doctor is the first person to oversee this procedure and is solely responsible for history , physical examination, care plans, operating documents, consent forms, used prescriptions, referral papers, discharge reports and medical certificates. The nursing care, laboratory results, medical examination reports, pharmacy records, and billing processes should be properly documented. This means the employee should also be skilled in keeping the patient records properly.

3. What repercussions might there be if she doesn't query and the medical record doesn't support her coding logic?

Fines could be levied, the doctor could lose his or her licence, and some might even face prison time. This practise is not only immoral and unlawful but may also have detrimental effects for the patient.