HIM professionals know that coding accuracy must be monitored and corrected when found to be below standard. At the same time, the speed at which records are coded must be efficient as healthcare organizations are faced with declining reimbursement and increased data collection.
It is the responsibility of the coder to assign codes based on documentation in the chart and as guided by the code-set and the official coding guidelines. But what happens when documentation in the chart is not clear cut?
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