We all know that medical coders do not have any power to make diagnosis decisions. They must apply a strictly literal interpretation to the healthcare provider’s medical record documentation. They are not allowed to make assumptions or presume to know the healthcare provider’s intent.
But, there is always a <<but>>: Guideline I.A.15.
I am still seeing so many medical coders missing the opportunity to code two conditions as related when they are linked by the word << with >> in the alphabetic index.
Indeed, this Guideline empowers medical coders to make certain diagnosis coding decisions without having to query the provider.
To read more about it, see the article published by AAPC by clicking the link: