When coding operative reports, is it required that the diagnosis be in the op note? For example, a provider states a colonoscopy is high risk on the op note but doesn't list the reason. Only when looking at the H&P do you find that the patient has a personal history of colon polyps. When billing for the provider, can we add the V12.72 even if it's not in the op note itself?
Thanks,
Sue
Thanks,
Sue