Reading the evidence behind a code
Check what in the clinical record supports each code Rhazes suggests, and the three things to look for before accepting one.
Updated
Every code shows its evidence
Rhazes shows what in the clinical record led to each code it suggests, so you can confirm the documentation genuinely supports it.
What to look for
- Does the evidence say what the code says? A code is only defensible if the record supports it.
- Is it from the right encounter? Particularly in a long chat covering more than one thing.
- Is it documented, or implied? A code resting on an inference rather than a documented finding is the one that fails an audit.
Codes you do not agree with
Leave them out. The suggestions are a starting point, and you are the one accountable for what gets submitted.