A county hospital coder is pressured to add a diagnosis that would…

Question

A county hospital coder is pressured to add a diagnosis that would raise CMI, but the condition is not documented in the inpatient record. Under AHIMA Standards of Ethical Coding, what should the coder do?

Accepted Answer

Refuse to assign any diagnosis that lacks supporting documentation in the current record. — Coding without documentation is like booking a charge on a receipt that never existed. Ethical coding means every code has support in the record—productivity pressure does not change that. Skip the unsupported diagnosis and stick to what is written.

Answer

Assign the diagnosis to meet productivity and CMI targets, then query later if needed.

Answer

Code the diagnosis as a queryable possibility and mark it as ruled out.

Answer

Use the previous admission's documentation to support the new code.

A county hospital coder is pressured to add a diagnosis that would raise CMI, but the condition is not documented in the inpatient record. Under AHIMA Standards of Ethical Coding, what should the coder do?

Short Explanation

Full Explanation