Question

A coder who believes a diagnosis was inadvertently omitted from the encounter documentation may ____ the physician, if possible.

a) Doubt
b) Query
c) Charge
d) Ignore

Answer 1

The coder should query the physician to seek clarification on a possibly omitted diagnosis to ensure accurate documentation and billing. Querying is essential for maintaining the accuracy of patient records and billing practices.

Step-by-step explanation:

A coder who believes a diagnosis was inadvertently omitted from the encounter documentation may query the physician, if possible. The correct answer is b) Query. In medical coding and billing, querying is a process where the coder seeks clarification from the physician regarding documentation in the patient’s record. This action is taken to ensure accurate coding and billing of patient services. Coders must use this process to correct or verify the information before it is used in the patient’s permanent health record and for billing purposes. It is crucial to maintain precise documentation for patient care, legal integrity, and proper billing.