When there is conflict in documentation, what is appropriate for code assignment?

When there is a conflict in documentation, querying the attending physician is the most appropriate course of action. This is because the attending physician is responsible for ensuring the accuracy of the medical record and can provide clarity on ambiguities found in the documentation. Their input can help resolve discrepancies, ensuring that the coding reflects the patient's condition and the services rendered accurately.

By reaching out to the physician, coders can obtain the necessary details or clarifications that may not be evident in the documentation. This promotes accurate coding and ensures compliance with coding guidelines, ultimately leading to proper reimbursement and better patient care.

Other options do not align with best practices in coding. Relying solely on staff nurses' observations does not consider the comprehensive clinical picture needed for accurate coding. Depending only on a coding specialist may overlook vital information that can only be clarified by the attending physician. Strict adherence to coder judgment without physician input could lead to coding inaccuracies, non-compliance, or misrepresentation of the patient's medical condition.