Patient XXX has four charges with four diffierent DOS.

All the first three records states "Malignant tumor"

The last one just states "Tumor" not stated as malignant. However its clear that the procedure performed is directed towards the malignant tumor.

1.Can we code "malignant tumor" for the fourth one. or

2.Should we ask for additional dictation from the physician to code this as malignant tumor.

which one is compliant 1 or 2.

Any input on this would be greatly appreciated!