There Is No Coding Without Physician Documentation

This episode of the CodeCast Podcast focuses on physician documentation as it relates to coding. There is a saying, “There is no coding without documentation, doctors are required to use words.” AHIMA and AHA stand behind this statement.

More and more I am seeing coders making leaps to moderate and even high risk for patient encounters, when there is no link, narratively, in the record made by the physician.

I want to talk about this as a compliance, and coding issue.

The Coding Clinic says yes, doctors are required to write words, and they go on to remind coders that ICD-10-CM is a statistical classification. The role of physician documentation is inherent in the use of the code set – because the process of coding is the translation of physician documentation into codes.

Check out this week’s program to understand how to make this process more compliant in your work-flow.

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