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What would be the correct action for the coder to take

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Question: The radiology report read by the radiologist in the patient's medical record for an inpatient hospital stay states the patient has a comminuted closed fracture of the left femur shaft, initial encounter. The attending physician has not documented the fracture in the patient's medical record. What would be the correct action for the coder to take in this situation? Is it necessary to query the physician or should the coder code the diagnosis from the radiology report since it is available in the medical record at the time of code assignment?

Reference no: EM133553531

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