Which general principle should guide coders when selecting codes?

Choosing the code that most accurately describes the service provided is crucial in medical coding. Accurate coding is essential for several reasons. First, it ensures that the medical record reflects the patient's condition and the services rendered, which is vital for quality patient care. Accurate codes facilitate proper billing and reimbursement processes, helping healthcare providers get appropriately compensated for their services.

Additionally, precise coding helps maintain compliance with regulations and guidelines set forth by entities such as the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA). This reduces the risk of audits and denials, which can result from billing errors or inaccurate coding.

Focusing solely on payment potential or personal experience may lead to unethical practices or inaccuracies, while referencing a patient’s insurance plan alone does not ensure that the code selected adequately describes the medical service. Therefore, the principle of selecting codes that accurately convey the services provided supports proper documentation, reimbursement, and compliance within the healthcare system.