A patient has adenocarcinoma of the uterus with a discharge note stating total removal of the uterus, while the pathology lists uterus, tubes, ovaries, cervical tissue, and lymph nodes. What should the CDI do?

• A. Clarify all of the above
• B. Accept the discharge summary as complete
• C. Recode based on the discharge diagnosis only
• D. Conclude the procedure was hysterectomy only

Answer: (A)

When documentation doesn’t line up, you must reconcile it to capture the true procedure performed. Here the discharge note says total removal of the uterus, but the pathology lists uterus, tubes, ovaries, cervical tissue, and lymph nodes. That combination points to a more extensive operation than a simple hysterectomy: it implies removal of the uterus with cervix (a total hysterectomy), plus bilateral salpingo-oophorectomy and removal of lymph nodes. Because coding should reflect exactly what happened, not just what the discharge summary states, you need a clarification to confirm the precise procedure and extent.

Clarify all of the above so you can code based on the actual operation and specimens removed rather than the discharge wording alone. Accepting the discharge as complete would overlook additional tissue removed; recoding solely from the discharge diagnosis would miss the surgical extent; concluding it was a hysterectomy-only would ignore the involvement of other organs and lymph nodes. A targeted clarification ensures the procedure and pathology align, enabling accurate codes and proper cancer staging documentation. In practice, this means consulting the operative report and confirming with the surgeon and pathology to determine the exact procedure performed.