Question

It is the coder's responsibility to assign codes completely and accurately so that a facility receives the reimbursement to which it is entitled. To meet this responsibility, a coder must:

A) Adhere to ethical coding practices
B) Use vague and general coding language
C) Avoid reviewing medical records thoroughly
D) Ignore clinical documentation improvement (CDI) specialists

Answer 1

A coder must adhere to ethical coding practices, thoroughly review medical records, avoid vague coding, and work with CDI specialists to ensure accurate coding for proper reimbursement and healthcare management.

Step-by-step explanation:

To meet the responsibility of assigning codes completely and accurately, a coder must:

• Adhere to ethical coding practices
• Avoid using vague and general coding language
• Ensure thorough review of medical records
• Engage with clinical documentation improvement (CDI) specialists when necessary

For example, when a patient is treated for a viral infection, precise ICD codes help to ensure that the appropriate laboratory tests are ordered, the correct treatments are prescribed, and reimbursement is accurately processed. ICD codes are crucial in many healthcare processes, such as the verification of treatments by health-care management systems and the recording of morbidity and mortality statistics by epidemiologists.

Two locations where you would likely find an ICD code are in medical laboratories on test forms and on death certificates kept by vital-records keepers.