In reviewing the medical record of a patient admitted for a left herniorrhaphy, the coder discovers an extremely low potassium level on the laboratory report. In examining the physician's orders, the coder notices that intravenous potassium was ordered. The physician has not listed any indication of an abnormal potassium level or any related condition on the discharge summary. The best course of action for the coder to take is to.

Question

Quizplus · Accepted Answer

The coder should confer with the physician to confirm if the low potassium level was clinically significant and if it needs to be listed as a final diagnosis. It is important to clarify any unclear or missing information with the physician to ensure accurate coding and billing.

In Reviewing the Medical Record of a Patient Admitted for a Left