We have certified professional coders on staff. Why can’t they assume a diagnosis based on my specific treatment or prescription?

If you have certified professional coders on staff, and you’ve given them the responsibility to abstract the records, make sure they don’t assume a diagnosis based on your specific treatment or prescription.

Coders should base their decisions on existing documentation. They should review the patient’s symptoms and the possible code selection with you, both to describe appropriately the patient’s true condition and to educate you on the choices the ICD-9-CM book offers. Tell coders also not to base codes on assumptions even to rule out possible and suspected conditions when you haven’t definitively diagnosed the condition. If they assign a specific diagnosis based on assumption, it has the potential of tagging a patient with a condition he or she doesn’t have, which may result in the loss of insurance coverage or an increase in premiums.