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. Yes the employee should query the provider.

2. It's not acceptable for the employee to code the patient record since she knew the answer, and didn't want to bother with the query.

3. There could be serious repercussions if she doesn't query and the medical record doesn't support her coding logic.

Medical Coding, the process by which medical procedures and diagnoses are represented and displayed by universal code numbers, is a system that plays a key role in modern healthcare operations. It allows organizations to communicate effectively with other healthcare systems throughout the US and the world.

Coding allows statistical analysis of diseases and treatments, diagnosis-related group reimbursement, and easier observance and tracking of epidemics or pandemic events. It also helps inform planning with the medical organization's decision support systems.

The pairing of coding with the hospital's data systems is what makes it such a powerful tool. With new trends in big data, which typically refers to large amounts of data from various sources stored and accessed from one large online data system, coding allows for implementation in even larger and more intriguing ways. For instance, Google Flu and Google Dengue allow for real-time tracking of disease activity, and could be important tools in the field of public health. Looking at data from this perspective might help doctors make more enlightened decisions about care.