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Wiki OP report vs procedure performed

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chankim

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Are you able to code a procedure that is described in the body of the OP-report but is not listed as a procedure performed section of the report?
 
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I definitely agree. As long as the services provided are documented, it should not matter what heading they are under.
Same applies to E/M services. If a clinician puts the exam under HPI heading, you still count it as the exam.
 
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