Question

Even though code assignment is usually based on the provider's documentation, what is the exception?

A) Patient's self-report
B) Nurse's assessment
C) Family member's report
D) Clinical coder's judgment

Answer 1

The exception to the rule of code assignment based on the provider's documentation is the clinical coder's judgment. However, this should be in adherence to coding guidelines and may require consultation with healthcare providers.

Step-by-step explanation:

Even though code assignment is usually based on the provider's documentation, the exception to this rule is D) Clinical coder's judgment. When documentation is unclear or insufficient, clinical coders may need to use their professional judgment to assign the most accurate codes. However, this practice should be based on coding guidelines and conventions and should be done in consultation with healthcare providers as necessary, not on alternatives such as A) Patient's self-report, B) Nurse's assessment, or C) Family member's report.