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Medical Coder

Real-Life Activities

Real-Life Decision Making

You sit down at your desk and begin to look over medical records from a patient who has come into the hospital for surgery. "Ah, good," you say to yourself as you flip open the records. It appears to be a routine surgery by a doctor that is usually very thorough and fair in her documentation.

You begin to apply codes for the hospital visit, including preoperative examination fees, room fees and the fees for the surgery itself. By the looks of the records, this is just another routine gallbladder removal.

You zip through applying codes. Then you notice that the doctor has written down that once the patient was under the knife, a more extensive type of surgery had to be performed. This is unusual for a gallbladder removal, so you decide to investigate other notes.

Nothing in the nurse's notes or in the surgical notes indicates that any further surgical procedures were performed on the patient. However, the doctor has indicated a more extensive surgical procedure was performed.

This is a doctor you know and generally trust. What do you do?