Canadian Health Information Management Association Practice Exam

As a HIM professional, what is your best option if you disagree with recommendations to code all conditions noted by any health professional?

1. Code all conditions as requested

2. Code all conditions as query diagnoses

3. Contact CHIMA immediately

4. Document and take your concerns to administration

The correct answer is: Document and take your concerns to administration

In the context of health information management, if a HIM professional disagrees with the recommendation to code all conditions noted by any health professional, the most appropriate course of action is to document the concern and take it to administration. This approach emphasizes the importance of maintaining the integrity of coding practices and ensuring that the coding accurately reflects the patient's medical records and conditions. By documenting the concerns, the HIM professional establishes a clear record of their perspective and can provide evidence for the rationale behind their disagreement. Bringing these concerns to administration allows for a discussion regarding ethical coding practices, compliance with coding standards, and potential impacts on data quality, reimbursement, and patient care. This route promotes collaboration among health information management teams and administration, which can lead to informed decision-making and possibly changes in coding guidelines that align better with best practices. It also aligns with the HIM professional's responsibility to ensure accurate and ethical coding, as they are advocates for both the accuracy of health records and the patients whose information they manage.