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What Are the Correct Steps to Coding for the Best

Question 4

Multiple Choice

What are the correct steps to coding for the best payment outcome?


A) Identify the reason for the encounter based on what the physician documented as the diagnosis without reviewing the medical record. Find the diagnosis in the Tabular List and choose the code with the highest specificity. Assign the code and submit to insurance.
B) Identify the reason for the encounter based on the diagnosed reason and confirmation within the medical record. Find the diagnosis in the Tabular List, confirm it in the Alphabetic Index, assign the code without regard to the specificity and submit to insurance.
C) Identify the reason for the encounter based on the diagnosed reason and confirmation within the medical record. Find the diagnosis in the Alphabetic Index, review entries for modifiers, choose the best code and locate it in the Tabular List, then determine whether the code is the highest level of specificity. If so, assign that code to the encounter. Sequencing is very important, so review this prior to final billing submission.
D) Identify the reason for the encounter based on what the physician documented as the diagnosis after reviewing the medical record. Find the diagnosis in the Alphabetic Index, find it in the Tabular List, and use the first code available without regard to modifiers or specificity.

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