ResiCAT_USER-GUIDE_ACT-edition_2014_92pp

ResiCAT User Manual

C LASSIFICATION OF C ODING C HANGES – R EASON FOR E RROR

7.2

Australian Coding Standard  The coder has failed to adhere fully to an Australian Coding Standard.   

It is recommended that, if it is clear that the coder understands a Standard such as those relating to  smoking status, allied health interventions or anaesthesia but has simply missed the code, then designate  the error as ‘Missed documentation’.  Missed Documentation  The coder has apparently not reviewed the record thoroughly and has therefore failed to abstract  relevant, readily‐available information.  Other coder error  The coder has made an avoidable error that does not fit into either of the first two categories.  Poor source documentation  The coder and auditor codes are different but the auditor has assessed that the source documentation  was of sufficiently poor quality that the coder’s choice of code was understandable.  Other  This category is provided for unavoidable errors such as might be caused by a computer system error or  the requirement to include a code because of a local coding rule.

Version 1.4

87