Explain the following statement: "Coding is to be done to the highest level of certainty."

What will be an ideal response?

This statement means that all relevant information in the chart should be coded, but missing information should not be assumed or coded. Only conditions, diseases, and symptoms documented in the medical record can be coded and billed. If the medical record is incomplete or inaccurate, it should be corrected or amended before attempting to code. It is important to keep in mind that when performing diagnosis coding in order to bill for services, the diagnosis must describe the reasons the specific service was provided and related medical conditions that may affect the specific service.