In coding practices, what must you do if additional information is needed for accurate coding?

Referring to a coding manual is essential for ensuring accuracy in coding practices because it provides standardized guidelines and official codes that are necessary for proper billing and documentation. Medical coding manuals, such as the ICD (International Classification of Diseases) or CPT (Current Procedural Terminology), contain detailed descriptions of conditions, procedures, and the specific coding needed to accurately represent a patient’s diagnosis and treatment.

Using a coding manual helps coders remain compliant with current coding standards, reduces the risk of errors, and ensures that the information aligns with regulations set by insurance companies and healthcare institutions. This resource serves as an authoritative reference that can clarify ambiguities in patient records or coding queries, ultimately supporting the integrity of the coding process. This is the recommended course of action whenever additional information is needed, as it relies on established knowledge rather than personal judgment or assumptions.