What should a coder do if it is unclear whether leukemia has achieved remission?

In cases where it is unclear whether leukemia has achieved remission, the appropriate action is to query the provider. This is important because accurate coding relies on precise and complete information. Engaging the healthcare provider ensures the coder receives the most current and specific details regarding the patient's status, which can include lab results, treatment responses, and physician assessments.

When coding is based on unclear information, like assuming the status or coding it as unknown, it can lead to inaccurate coding that may affect patient records, treatment plans, and insurance reimbursements. Querying the provider helps maintain the integrity of the medical record and supports the objective of coding for quality patient care. It also aligns with coding guidelines that emphasize using the most definitive information available.