Posted: July 14th, 2022

Our lecture discussed the ICD-10-CM manual (indexes, tabular list, appendix) and the correct steps to find and assign an ICD-10-CM code. It also touched upon certain areas of a patient’s record that coders should not use when assigning a code.

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Our lecture discussed the ICD-10-CM manual (indexes, tabular list, appendix) and the correct steps to find and assign an ICD-10-CM code. It also touched upon certain areas of a patient’s record that coders should not use when assigning a code. In at least 150 of your own words, reflect on the following:
Based on coding guidelines, coders may only code from a physician or other qualified healthcare provider’s notes. Discuss why you think this is a requirement and whether you agree. Explain your reasoning for why or why not.
In relation to the prompt above, consider the following scenario and explain the correct course of action. While reviewing a patient record, you notice documentation in the nursing notes that may conflict with the physician’s diagnosis. As a coder, what is your responsibility in this case, and how do you proceed?

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