American Academy of Professional Coders (AAPC) Practice Exam

What must a coder evaluate when reviewing a medical record?

1. Completeness and accuracy

2. Patient demographics

3. The provider's credentials

4. Insurance policy details

The correct answer is: Completeness and accuracy

When reviewing a medical record, the coder must evaluate the completeness and accuracy of the documentation. This is essential because accurate coding relies on comprehensive and precise information from the medical record, which reflects the patient's treatment and the services provided. If the documentation is incomplete or inaccurate, it can lead to incorrect coding, resulting in potential compliance issues, payment delays, or denials. Completeness ensures that all necessary details are included, such as diagnoses, procedures performed, and any relevant clinical findings. Accuracy involves confirming that the information matches the services rendered and adheres to coding guidelines. Therefore, evaluating these aspects is crucial for achieving proper coding and ensuring appropriate reimbursement.