A Coder Reviews a Patient's Medical Chart and Reads a Laboratory

Multiple Choice

A coder reviews a patient's medical chart and reads a laboratory report of blood work ordered by the physician after the patient's last visit. The patient presented with a chief complaint of general weakness and persistent cough as documented in the medical record and no further definitive diagnosis is documented. The coder sees that presence of HIV is confirmed in the laboratory report. The coder should:

A) Code general weakness only
B) Code general weakness and persistent cough
C) Code HIV only
D) Code HIV, general weakness, and persistent cough