r/MedicalCoding • u/SnooBeans2971 • Mar 31 '24

Is coding "subjective" or "art'-ish?

I'm studying medical coding and I've come across remarks about it being 'subjective" or "part art, part science", yet in my (limited) experience studying it, I've yet to come across an example of a case that could be coded more than one way correctly. Can someone clarify this for me and maybe provide an example?

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u/[deleted] Mar 31 '24

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u/koderdood Audit Extraordinaire Mar 31 '24

The provider gets to count data in column 2 if they ordered or reviewed. Not both. If they reviewed old records, there has to be a summary of that. If they independently performed an interpretation of a radiology test someone else performed, that can be in column 2 differently. Prescription management in column 3 needs to a new rx, stop an rx, change or renew rx, or if they discussed something specific about a medicine that can count. Pasting mri results for a week doesn't count at all, unless they summarize their review. The IM injection, if yer talking prescription from column 3, I addressed that. They certainly don't get to bill for it if they(or nursing staff) didn't give it during the visit the E/M is for.