Included among the eight guidelines established by the industry trade group for records professionals are these words of advice:
Documentation must be assessed to ensure it is adequate and
appropriate to support the diagnoses and procedures selected.
Physicians should be consulted for clarification when they enter
conflicting or ambiguous documentation in the chart.
Medical record coders should assist physicians unfamiliar with DRGs or othercoding methodologies by suggesting a change in sequence or the inclusion ofdiagnoses or procedures to more accurately reflect events during an encounter.
Diagnoses in a medical record that would not be abstracted if they did not influence payment should not be included.
Medical record coders are "expected to strive for the optimal payment to which the facility is legally entitled, but it is unethical and illegal tomaximize payment by means that contradict regulatory guidelines."
Source: American Health Information Management Association