HEALTHCARE CONSUMERS ARE unique. Each person has his or her own combination of medical conditions that organizations must somehow standardize for data comparison. One way to capture these data is by translating clinical documentation into codes such as ICD-9-CM and CPT.Historically, in the inpatient setting, data collection occurred after the patient was discharged. After discharge, HIM professionals checked the record for discrepancies that could hinder code assignment. HIM professionals would then query the pro-vider for clarification. (For purposes of this practice brief, the term "query" will be used to identify any physician communication tool.)
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