Who is solely responsible for coding patient encounters?

The correct answer is the providers. They are the healthcare professionals who directly interact with patients, assess their medical conditions, and determine the appropriate diagnoses and treatment plans. This hands-on experience allows providers to accurately code patient encounters based on detailed clinical findings and the comprehensive medical history they gather during patient visits.

Providers have the clinical training necessary to understand and apply coding systems effectively, ensuring that the coding reflects the services rendered and the patient’s condition accurately. This is crucial for proper billing and reimbursement processes, as well as for maintaining the integrity of medical records.

While nurses, medical technicians, and administrative staff may support aspects of patient care and documentation, it is ultimately the providers who hold the responsibility for coding encounters, based on their clinical expertise and direct involvement with patients.