Canadian Health Information Management Association Practice Exam

Which coding process involves the review of documentation concurrently with the patient's stay?

1. Retrospective coding

2. Concurrent coding

3. Prospective coding

4. Audit coding

The correct answer is: Concurrent coding

The coding process that involves the review of documentation concurrently with the patient's stay is known as concurrent coding. This approach allows healthcare providers or coders to analyze the medical records as the patient is actively receiving care. The primary benefit of concurrent coding is that it enables the identification of gaps in documentation while the patient is still in the facility, allowing for timely corrections or additions that can improve the overall quality of the medical record. Concurrent coding is particularly advantageous for ensuring accurate coding and billing for services rendered. By reviewing the documentation as it is created, coders can assist in capturing all relevant diagnoses and procedures, thus reducing the likelihood of discrepancies and potential revenue loss. In contrast, retrospective coding occurs after the patient has been discharged, making it impossible to gather additional documentation or clarification from providers about the treatment provided. Prospective coding refers to a preemptive coding model that involves coding before services are rendered, often used in scenarios involving predetermined reimbursement rates. Audit coding is a review process used to ensure compliance and accuracy but is distinct from these types of coding processes and typically happens after the coding has been completed.