What steps do you take when clinical documentation conflicts with diagnosis codes?

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When clinical documentation conflicts with diagnosis codes, it’s crucial to resolve discrepancies to ensure accurate, compliant coding. Here’s my approach:

1. Thoroughly Review Documentation:
   I carefully re-examine the entire medical record—physician notes, lab reports, imaging, discharge summaries—to understand the clinical picture and identify inconsistencies.

2. Verify Coding Guidelines:
   I check official coding guidelines (ICD-10-CM, CPT) and payer policies to confirm correct coding rules related to the conflicting diagnosis.

3. Identify Specific Conflicts:
   Pinpoint exactly where documentation and coded diagnoses disagree—for example, a diagnosis coded but not supported by clinical findings or vice versa.

4. Query the Physician:
   I submit a clear, compliant query to the physician requesting clarification or additional documentation to resolve the conflict. Queries are carefully worded to be objective, non-leading, and compliant with regulatory standards.

5. Hold Off on Final Coding Until Resolution:
   If possible, I delay final coding decisions until I receive clarification, ensuring that codes accurately reflect the patient’s condition.

6. Use Coding Judgment When Necessary:
   If a query isn’t possible and documentation remains contradictory, I code to the highest level of certainty supported by the clinical record.

7. Document Coding Decisions:
   I document all steps taken, including the query process and rationale for coding choices, to maintain transparency and facilitate audits.

8. Educate and Collaborate:
   I work with providers to improve documentation quality, reducing future conflicts.

By following these steps, I ensure coding integrity, compliance, and accurate reflection of patient care.

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