Sally Smith is reviewing an inpatient record for coding. She notes that the face sheet, diagnostic testing reports, and discharge summary contain different diagnoses. What should she do to code the diagnoses?
A) Use the diagnoses on the face sheet.
B) Select all the diagnoses on all three forms of documentation.
C) Use the diagnoses on the discharge summary.
D) Query the provider for clarification.

Question

Quizplus · Accepted Answer

When there are conflicting diagnoses in the medical record, it is the coder's responsibility to clarify with the provider to ensure accurate coding. Therefore, the best choice is to query the provider for clarification.

Sally Smith Is Reviewing an Inpatient Record for Coding