By Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC

I’ve never met an experienced coder who wasn’t told at one point or another that they “coded a record wrong.” Usually, by someone with no coding education or experience, typically because he/she doesn’t like the outcome(s) of the codes assignment as related to payment, quality measures, medical necessity, or some other initiative dependent on claims data. This can be frustrating when coder knows the Official Guidelines for Coding and Reporting were followed and, indeed, the record was coded right.

Personally, I come from a clinical background, working as a nurse, and transitioned into CDI more than 10 years ago. My inpatient coding team taught me basics and patiently explained and re-explained to me why the record needed to be coded in a particular way. As I grew in my experience, I began to understand that clinical language does not translate into codes as easily as one might think.