A coder reviews a patient's medical chart and reads a laboratory report of blood work ordered by the physician after the patient's last visit. The patient presented with a chief complaint of general weakness and persistent cough as documented in the medical record and no further definitive diagnosis is documented. The coder sees that presence of HIV is confirmed in the laboratory report. The coder should:

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The Answer of A coder reviews a patient's medical chart and reads a laboratory report of blood work ordered by the physician after the patient's last visit. The patient presented with a chief complaint of general weakness and persistent cough as documented in the medical record and no further definitive diagnosis is documented. The coder sees that presence of HIV is confirmed in the laboratory report. The coder should:

A Coder Reviews a Patient's Medical Chart and Reads a Laboratory