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I normally code the op report documentation. Please help me clarify some information. If the op report has a unilateral dx code, but the H/P has it listed as bilateral, should the bilateral dx code be used?
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.