Health Information Management

Is asking for clarification 'leading'?

Briefings on Coding Compliance Strategies, June 1, 2008

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by Robert S. Gold, MD

In 2000, CMS released a note that forbade individuals from asking physicians questions and assigning codes from their answers. CMS followed this with a subsequent note stating that it was acceptable to ask physicians questions and to assign codes from their answers. And HIM professionals have been in a quandary as to how to ask questions ever since.

Eventually, a Code of Ethics was published that included a statement saying it is inappropriate to ask a “leading” question. And just as in the previous sentence, the word “leading” was in quotation marks. However, the Code of Ethics didn’t define “leading.” It left it up to the interpreter to do so.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Coding Compliance Strategies.

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