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As stated in the Introduction to the International Classification of Diseases Ninth Edition (ICD-9) Official Guidelines for Coding and Reporting, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses.
The importance of consistent and complete documentation in the medical record cannot be overemphasized. The medical record documentation, from any provider involved in the care and treatment of the patient, may be used to support the determination of whether a condition was present on admission or not.