Computer-assisted coding (CAC) soft-suggests a secondary diagnosis that does not appear in any provider documentation. What is the hospital coder's correct validation step?
Select an answer to reveal the explanation.
Short Explanation
CAC is a helpful highlighter, not the attending. If the engine whispers a diagnosis that no provider wrote, you do not rubber-stamp it. Open the chart, prove the documentation, then accept or reject the suggestion.
Full Explanation
CAC and encoder suggestions accelerate coding but do not replace validation against the legal health record. Every diagnosis and procedure code must be supported by provider documentation (or other allowable sources per guidelines). Confidence scores and DRG similarity are not documentation. Coders should reject unsupported soft-codes and pursue clarification only when clinical indicators justify a query, never by placing undocumented codes on the claim.