What should a coder do if they find a positive lab report for staph infection, but the physician does not document it?

When a coder discovers a positive lab report indicating a staph infection but does not find corresponding documentation from the physician, the appropriate action is to query the physician. This step is crucial because proper coding relies on accurate and complete documentation. The physician’s confirmation of the lab findings ensures that the medical record accurately reflects the patient's diagnosis and supports coding guidelines.

Querying the physician allows the coder to seek clarification or additional information regarding the staph infection. This process helps maintain the integrity of the coding and billing process, promotes accurate representation of the patient’s medical condition, and prevents any potential compliance issues that might arise from coding based solely on lab results without physician documentation.

Using the lab report alone for coding could lead to inaccuracies and improper billing, as the coder is not authorized to make remote conclusions without the physician’s explicit documentation. Furthermore, documenting the lab results independently does not align with the coding standards, and reporting to the compliance officer may not be necessary unless there are larger concerns regarding documentation practices. Therefore, seeking clarification through a query is the best practice in this situation.