An encoder defaults a secondary diagnosis code that is not supporte…

Question

An encoder defaults a secondary diagnosis code that is not supported by the discharge summary or progress notes and would violate Official Guidelines. What should the facility coder do?

Accepted Answer

Override the unsupported encoder default and assign codes that match documentation and Official Guidelines. — When the software defaults something the chart doesn’t support, you’re the adult in the room. Override it. Guidelines and documentation beat a convenient default every time.

Answer

Keep the default to protect case-mix index and document “software assigned” in the query log.

Answer

Ask the billing office to hard-code a bypass so encoder defaults always post to the claim.

Answer

File a HITECH breach report because any encoder default equals impermissible PHI disclosure.

An encoder defaults a secondary diagnosis code that is not supported by the discharge summary or progress notes and would violate Official Guidelines. What should the facility coder do?

Short Explanation

Full Explanation