Health Information Management

Q&A: Coder documentation in the medical record

HIM-HIPAA Insider, April 20, 2010

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Q: May coders document in the medical record?

A: The word “document” is very abstract in this question. Coders may not determine and document any diagnosis, recommendations, or suggestions for treatment. Coders may include information from other qualified sources in the record, such as laboratory results or a report from a consulting radiologist. Coders also may transcribe or enter data that attending physicians verbally convey to them; however, the attending physician must personally sign off on that information before it becomes an official part of the patient’s record.
 
Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question in the April 2010 issue of Briefings on Coding Compliance Strategies.



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