Question

What action(s) should the coding staff take?

1) Query the physician.
2) Assign the codes for the postoperative transplant rejection.
3) Assign only the code for the transplant rejection.
4) Assign only the code for heart failure.

Answer 1

The coding staff should initially query the physician for clarifications if required. After clarification, they should assign the appropriate codes for postoperative transplant rejection and heart failure, if both conditions are documented and confirmed through querying.

Step-by-step explanation:

The coding staff should take the following action(s):

1. Query the physician: The staff should reach out to the physician for clarification, if needed, to ensure accurate coding.
2. Assign the codes for the postoperative transplant rejection: The staff should assign the appropriate codes for the postoperative transplant rejection, as this is a specific diagnosis that occurred after the surgery.
3. Assign only the code for the transplant rejection: If the physician provides documentation indicating only the diagnosis of transplant rejection, then the staff should assign the specific code for transplant rejection.
4. Assign only the code for heart failure: If the physician provides documentation indicating only the diagnosis of heart failure, then the staff should assign the specific code for heart failure.