Provider documentation ICD 10

aamelkin

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We code for a pain practice from the surgical note. The provider will put in Post OP diagnoses: cervical disc degeneration
However down through the body of the note where he describes the procedure he does list the actual levels that he injected. So we code based on this description to the high cervical region, mid-cervical region or cervicothoracic region based on the procedure note. If the notes were audited is it okay how we are doing this or should the provider put in his post op diagnoses area of the note: the acutal high cervical region cervical disc degeneration, ?
The post op dx given would support: M50.30 but if you read the note the note supports M50.31 or M50.32 or M50.33 depending on the levels injected.
Any guidance on this would be appreciated.

Thank you
 
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