What should coders avoid doing when interpreting documentation?

Coders should avoid extrapolating or assuming when interpreting documentation because these actions can lead to inaccuracies in coding. Coding guidelines emphasize the importance of using only the information that is explicitly documented in the patient’s records. Extrapolating or making assumptions introduces a risk of misinterpreting the clinical details, which can result in incorrect code assignment and potentially affect reimbursement, compliance with regulations, and patient care outcomes.

When coders stick to the documented facts, they ensure that the coding reflects the actual services provided and the patient's conditions as defined by healthcare providers. This practice upholds the integrity of health records and supports accurate data for reporting and billing. Avoiding assumptions helps maintain clarity and consistency in coding practices.