Which action best reflects the CDI approach when a chart indicates active surveillance for a condition that may be mischaracterized as cancer?

• A. Recommend clarification rather than assuming a cancer diagnosis
• B. Accept the chart as written to avoid delays
• C. Update the diagnosis to cancer without documentation
• D. Defer to patient report for diagnosis

Answer: (A)

When a chart shows active surveillance for a condition that could be misread as cancer, the key idea is to verify the actual diagnosis before coding. The CDI approach is to seek clarification from the treating physician or review documentation to determine whether cancer is confirmed, ruled out, or only suspected. This ensures the code reflects the true clinical situation—if cancer is not established, coding should not state cancer; if there is suspicion or a plan to monitor, that intention should be documented and coded appropriately. By recommending clarification, you prevent mislabeling and potential inaccuracies that could affect patient care, reporting, and compliance.

Accepting the chart as written would risk coding a cancer diagnosis without definitive documentation, which can lead to inappropriate treatment claims and downstream problems. Updating the diagnosis to cancer without documented confirmation similarly bypasses proper verification. Deferring to patient report ignores physician documentation and diagnostic work, which are the proper sources for coding decisions. The right move is to obtain precise, physician-authenticated clarification about whether cancer is diagnosed, suspected, or under surveillance, and to code accordingly.