Question

If a fracture is not documented, does the coder assume it is closed?

1) Yes
2) No
3) Cannot be determined

Answer 1

No, the coder does not assume a fracture is closed if it is not documented.

Step-by-step explanation:

No, if a fracture is not documented, the coder does not assume that it is closed.

A fracture can be either open or closed, depending on whether the bone protrudes through the skin or not. Without documentation, the coder cannot determine the type of fracture.

For accurate coding, it is important that a fracture is properly documented by a healthcare professional.

Answer 2

If a fracture is not documented, the coder should not assume its status (Option 3 - Cannot be determined).

Step-by-step explanation:

Coding Principles: In medical coding, assumptions should be avoided. If a specific detail, such as the status of a fracture (open or closed), is not explicitly documented in the medical records, the coder should not make assumptions about it.

Accuracy and Clarity: Accurate coding is crucial for healthcare billing and patient records. Coders are trained to code only based on information available in the medical documentation. Making assumptions can lead to inaccuracies and potential legal or billing issues.

Querying for Clarification: If there's uncertainty or missing information in the medical records, coders may initiate queries to healthcare providers seeking clarification on the patient's condition or any missing details.

Option 3 (Cannot be determined) is the answer.