What should coders avoid doing when interpreting the medical record?

When interpreting the medical record, coders must base their coding decisions on the actual documented information rather than assumptions or extrapolations. This approach ensures accuracy and compliance with coding guidelines. By relying solely on what's documented in the medical record, coders maintain the integrity of the coding process and support proper reimbursement for the services provided.

The act of assuming or extrapolating information can lead to coding errors, which may result in incorrect billing, compliance issues, and potential legal ramifications. Medical records contain specific information that must be interpreted exactly as it is presented, reflecting the provider's clinical judgment and findings.

Utilizing provided templates can be a helpful resource, as they guide coders through common procedures and diagnoses. Consulting multiple sources can enhance understanding and ensure that coders have a complete view of the patient's condition and history. Documenting the principal diagnosis is a necessary part of the coding process, as it is crucial for billing and medical record accuracy. Overall, the importance of relying on documented information cannot be overstated, making the need to avoid assumptions clear.