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Wiki Surgical Coding of an Operative Report

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karenlw18

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When coding for an operative report, from what sources can you pull ICD-10 information? You can use the operative report itself as well as any information from the related pathology report but can you use other sources, such as the H&P, another provider's notes, previous pathology and/or op reports, etc?
And please provide information from a documented source rather than opinion as this information is needed for research by a compliance department.
Thank you
 
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