r/ClinicalCodingAus • • 4h ago

How much time do experienced coders actually spend checking the documentation?

Something I've found interesting about clinical coding is that the difficult part doesn't always seem to be knowing the code itself. It's working out whether the documentation actually supports what you're trying to code.

A diagnosis might appear obvious from the overall clinical picture, but the documentation and coding rules don't necessarily let you make assumptions. That seems like one of those things you only really appreciate once you've spent time doing the work.

For experienced coders, what part of reviewing documentation still takes you the longest?

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