If a service is not documented in the medical record, what should the coder's action be?

The correct action when a service is not documented in the medical record is to ignore the service entirely. This is based on the principle that coding must reflect only the services that are documented and substantiated in the medical record. Accurate coding requires a clear link between the documentation and the services provided to ensure compliance with regulations and reimbursement policies.

When a service is not documented, it cannot be coded or billed, as there is no official record to verify that the service was actually performed. Accepting or assuming that a service was provided without documentation could lead to compliance issues or audits, as it would misrepresent the care given and potentially result in fraud.

In situations where there is a service that is believed to have occurred but is absent from the record, the appropriate course of action would typically involve reviewing the documentation process or consulting with relevant staff, such as the clinical medical assistant, for clarification, rather than coding a service based on assumptions or incomplete information.