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Dear all, I need help on this. Is answer B correct, and why? Please advise, thank you so much!
A patient's discharge summary does not contain a diagnosis that is documented by the anesthesiologist in a preoperative evaluation and that the diagnosis would impact MS-DRG assignment. The coder finds no evidence that the diagnosis contradicts documentation from the attending physician. The coder should:
a. Code only from the discharge diagnosis
b. Code the diagnosis reflected on the anesthesia preoperative evaluation
c. Code the most severe symptom
d. Query the attending physician regarding the clinical significance of that diagnosis
A patient's discharge summary does not contain a diagnosis that is documented by the anesthesiologist in a preoperative evaluation and that the diagnosis would impact MS-DRG assignment. The coder finds no evidence that the diagnosis contradicts documentation from the attending physician. The coder should:
a. Code only from the discharge diagnosis
b. Code the diagnosis reflected on the anesthesia preoperative evaluation
c. Code the most severe symptom
d. Query the attending physician regarding the clinical significance of that diagnosis