What is the first step in the procedure for code assignment in healthcare?

The first step in the procedure for code assignment in healthcare is to review clinical documentation. This step is crucial because accurate code assignment relies on understanding the patient's medical records, including the physician's notes, diagnostic documents, and treatment plans. By thoroughly reviewing this documentation, coders can gather the necessary information regarding diagnoses and procedures that occurred during the patient encounter. This foundational understanding ensures that the subsequent steps, such as identifying the correct diagnoses and procedures and ultimately assigning the appropriate codes, are performed correctly, leading to accurate billing and data reporting. Without this initial review, there is a risk of misinterpretation or omission of critical information, which could lead to coding errors or inaccurate healthcare data.