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BC Advantage - 2020 Issue 10

One of The Best Strategies for Risk Adjustment Medical Coders: Query the Physician or Other Healthcare Provider

Medical records report the care a patient received in a chronological order and are used to record pertinent findings and observations about the patient's health history. Medical record documentation assists physicians and other healthcare professionals in evaluating and planning the patient's immediate treatment and monitoring the patient's healthcare over time. Therefore, the medical documentation is essential and must be clear and concise.Apart from the possibility, according to ICD-10-CM Guideline I.A.15, to link certain diagnoses themselves, the medical coders do not have any power of diagnosis coding decision. They must apply a strict literal interpretation to the...

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