Wiki Clarification on documentation

[pfwilliams39]

If the provider documented a unilateral dx code on the op report and the procedure is unilateral, but the H/P has a bilateral dx code listed. Would the bilateral code be appropriate to code? I'm looking for a cps assist or ama guideline as well.

 

[natashalage]

Hello, I am not an expert. I take dx from the Op note. If the Op note describes the procedure bilaterally but the Op note has Dx is unilateral, I would query the Md and ask him to correct dx in the Op note.