American Academy of Professional Coders (AAPC) Practice Exam

What must a coder do with medical records?

1. Approve claims based on payment amounts

2. Read and understand the documentation in the medical record

3. Submit the medical records to the insurance carrier

4. Store the medical records indefinitely

The correct answer is: Read and understand the documentation in the medical record

A coder's primary responsibility regarding medical records involves accurately reading and understanding the documentation contained within them. This is essential because coding relies on the thorough and precise interpretation of the medical information provided by healthcare professionals. Coders must ensure that they capture all relevant diagnoses and procedures to assign the correct codes, which ultimately affects billing and reimbursement processes. Understanding the medical record is crucial for accurately translating the written medical documentation into standardized codes for various systems, including CPT (Current Procedural Terminology), ICD (International Classification of Diseases), and HCPCS (Healthcare Common Procedure Coding System). This process requires familiarity with medical terminology, anatomy, and the principles of coding guidelines, making comprehension of the documentation foundational to effective coding. While submitting records to insurance carriers, approving claims, and storing records are important activities within the medical billing and coding process, they do not encapsulate the core responsibility of the coder. The integrity of the coding process hinges on the coder’s ability to read and interpret the medical records accurately, ensuring that all services rendered are well-represented through the appropriate coding.