Coders and billers should never
assume a condition without
proper documentation or clari-
fication from the physician. It's
a common problem in a lot of
facilities. The coder reviews the
op notes and sees that the doc
failed to document a key com-
ponent of the procedure. He
sends her a message saying,
"You failed to establish the con-
nection between hypertension
and heart failure in the notes.
I'll go ahead and change it, if
that's correct." The coder could
be right, but the doc may resent
his tone and ignore or delay
response.
Instead, the coder should
send a message simply saying
he wanted to clarify whether
there was a connection
between the hypertension and
heart failure. It's to the point,
requires a yes or no answer and
doesn't seem like he's pointing
fingers.
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