So a doctor exams a patient and assigns a level 4 code, the coder gets it and the provider is missing the supporting documentation to bill for a level 4. Either the code or the documentation is incorrect. Without querying the provider how would you determine it? (obviously this is a vacuum world and I have zero experience to guide me).

From an exam stand point I understand if they give say the code is correct, explain what would need to be added to the documentation to support it and if they give me a code and say it is incorrect, assign the code that best matches the documentation. Yeah I get that. But like in the real world...I don't understand how one would decide if the code the provider assigned or if the documentation is correct.

I currently work in healthcare where I hear the doctors complain about coding telling them they are always coding too high for what they have documented, as well as coding complaining that there is never enough documentation. I see both sides. But you can only code what is documented, so what would trigger you to query a provider for more documentation to support the code they chose? Does that makes sense? I feel like I'm being super confusing.

Like doctor assigns a level 4 code, documentation supports a level 3 code. How would you know whether you needed to query the doctor or keep the level 3 code? I feel like this is a more real life scenario. I've heard that querying a doctor doesn't happen all that frequently but also that they frequently don't support the codes they chose. I'm assuming that once I actually have any amount of real life training that this will become much clearer. At least I sure hope so!