A pathology report showing malignancy appears in the chart, but the accession identifiers do not clearly match the patient under coding review. What must the coder do before coding the cancer?
Select an answer to reveal the explanation.
Short Explanation
Wrong-patient pathology is a nightmare scenario — verify the accession against the patient before you code cancer. A mismatched report is a stop sign, not a coding hint. Identity first, diagnosis second.
Full Explanation
Identity validation is a critical documentation-integrity step when attaching diagnostic reports to coded data. Coders must confirm that pathology accessions, patient names, and medical record numbers align before reporting malignancy. Coding from a mismatched or ambiguous report risks catastrophic clinical and reimbursement errors. Compromising with an alternate neoplasm code or trusting a filename without identity checks is unacceptable; escalate mismatches through proper channels.