What should be done if there is a disparity between clinical and pathological findings?

When there is a discrepancy between clinical and pathological findings, it is essential to query the physician for clarification. This approach is vital for several reasons.

First, the clinical findings may have been influenced by the patient's symptoms or other health conditions but may not fully reflect the actual pathology observed during examination. By reaching out to the physician, you can gain insights that may help reconcile the differences and lead to a more accurate depiction of the patient's condition.

Second, accurate coding is crucial in oncology, as it impacts treatment decisions, patient care, and reporting for clinical trials. Therefore, obtaining clarification ensures that the information documented and coded aligns with the best understanding of the case at hand.

Finally, querying the physician supports the principle of data integrity in medical coding and contributes to more reliable analysis and outcomes in oncology research and treatment planning. This proactive communication fosters a team-oriented approach, ultimately benefiting patient care.