Coding Tip Corner – July 2026

Our team would like to thank everyone for cooperating with our requests for medical records in a timely manner. We know this can place a strain on the office staff, but we are under a very tight time constraint with CMS requests for the records. Thanks for your full cooperation as we continue to meet the audit timeframes. 

Some Friendly Reminders

Remember the Golden Rule of medical coding: “If it wasn’t documented, it didn’t happen.” Here are a few errors or omissions we are seeing in the current medical records: 

1. Current vs. History specific to cancer 
2. Diabetes with complications (then diabetes with unspecified or other complications) is what is documented. Actual complication is not specified. 
3. CKD without documentation of labs or current treatment 
4. Laterality is missing 

Coders, if you see something is missing, please say something! 

A Word of Caution about AI

If your practice has chosen to use AI, please be aware that physicians remain responsible for the accuracy and completeness of their medical documentation. The provider remains responsible for what is documented in the patient’s record. 

AI can and does occasionally misinterpret medical terms, miss nonverbal cues, or even generate “hallucinated” facts! 

An important reminder to both providers and coders: Liability remains 100% with the provider, meaning they can be penalized for signing off on a flawed automated note.