Should an assumption be made based on a patient's age if Medicare is not mentioned?

Making assumptions based on a patient's age, especially in the context of medical coding for Medicare patients, can lead to inaccuracies in coding and billing. Each patient should be evaluated based on their specific medical history, diagnoses, and the procedures performed rather than being stereotyped by their age.

In situations where Medicare is not mentioned, coders must rely on the actual clinical documentation provided. The focus should be on the details of the patient's condition and treatment rather than assumptions that might not apply to every individual. Making unfounded assumptions could result in misrepresentation of the patient's health needs and potentially impact the reimbursement process.

This approach aligns with best practices for medical coding, which emphasize accuracy and adherence to documented information rather than generalizations about patients based on extraneous factors like age.