A poll from ICD10 Monitor shows how professional coders assign codes, and it turns out physician documentation is incredibly important.
The majority of respondents said they assign codes based on physician documentation even after querying the physician, regardless of the clinical indicators. Here are five statistics:
1. Query physician and assign codes based on physician query response and documentation regardless of clinical criteria documentation: 52 percent
2. Skip the query and assign codes based on physician documentation regardless of clinical criteria documented: 10 percent
3. Query physician but assign codes based on clinical criteria regardless of query response and physician documentation: 9 percent
4. Coding professionals do their own coding: 2 percent
5. Skip the query and assign codes based on clinical criteria regardless of physician documentation: 1 percent
The article's author called for official auditing guidelines and for those guidelines to be made public.