An implant sticker is in the inpatient chart, but the surgeon never documents the device in the operative report. The coder needs a PCS device character. What is the best next step?
Select an answer to reveal the explanation.
Short Explanation
A sticker in the chart is a breadcrumb, not the whole sentence. For PCS device characters, you need the implant documented in the record body—ask the surgeon to put the device in the op note if it is missing.
Full Explanation
ICD-10-PCS device characters require documentation support in the health record. An implant sticker may help identify a device but does not replace operative documentation of what was implanted. Coders should obtain clarification so the device is documented before assigning the device character rather than coding from the sticker alone or defaulting to no device.