An inpatient who had a biopsy is discharged, but the pathology report is not yet on the chart and pathology findings would change the diagnosis or procedure coding. What is the appropriate coding response?
Select an answer to reveal the explanation.
Short Explanation
If the path report is the missing puzzle piece, do not finish the picture with a guess. Park the chart under incomplete-record rules until pathology is in when those results drive the codes.
Full Explanation
When pathology is required for accurate diagnosis or procedure coding, coders should follow facility incomplete-record procedures rather than finalizing speculative codes. Permanent unspecified coding without update, or relying on undocumented verbal comments, undermines compliance and data quality. Timely retrieval of pathology supports accurate final coding after discharge.