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Wiki Clarification on documentation

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pfwilliams39

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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.
 
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.
 
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