Certified Inpatient Coding (CIC) Practice Exam 2026 - Free CIC Practice Questions and Study Guide

A coder should query a physician when documentation is incomplete or inconsistent because it is crucial for accurate coding that the medical records reflect a clear and thorough account of the patient’s condition and the services provided. Incomplete or inconsistent documentation can lead to misunderstandings regarding the patient’s diagnosis, the procedures performed, and their significance to the treatment provided. Thus, when a coder encounters vague, contradictory, or insufficient information in the medical record, it raises the need for further clarification from the physician to ensure that all coding assignments are accurate and compliant with guidelines.

The other choices, while they touch on relevant scenarios, do not address the primary reasons for querying a physician as effectively. For instance, unclear coding guidelines are often resolved with research and reference to official coding books or resources rather than direct queries to a physician. The refusal of treatment by a patient is more about patient autonomy rather than documentation needed for coding. Lastly, while audits might raise concerns about documentation, they typically don’t provide a direct reason for querying a physician at that immediate moment unless specific inconsistencies related to patient care arise.