When a patient is in the hospital-inpatient setting, and the hospitialist sees the patient let's say 5 days in a row, on 11/1, he says pulmonary embolism, but then the next day 11/2-he just says embolism, doesn't specify 'pulmonary' embolism, what would you code? Can I still say pulmonary or just embolism unspecified? If there's an audit, do they go by date of service? Or pull the whole chart? Also, this paticular hospitialist said prostate cancer in one date of service, but then a couple dates of service later, just said cancer. Well I know from 2 dates prior that it's prostate, can I use prostate although he just said cancer in that paticular date of service?
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