One day, an employee was coding an inpatient record at City Hospital. The physician’s documentation was…
One day, an employee was coding an inpatient record at City Hospital. The physician’s documentation was not clear on a high acuity patient; therefore, the employee needed to query the physician for clarification. The employee knew the answer to her question and was tempted to bypass querying the provider and just code the patient’s record based on what she knew. She was tired of all the querying!
1. Should the employee query the provider?
2. Is it acceptable for the employee to code the patient record since she knew the answer, and didn’t want to bother with the query?
3. What repercussions might there be if she doesn’t query and the medical record doesn’t support her coding logic?