#1 is an ongoing problem for anyone who codes from a superbill/encounter form. Best case is to code from documentation. We have some docs who do assign the codes. If we are using a superbill/encounter form, we make sure this is signed by the physician and is incorporated into the chart because we have found that the dx do not always match the documentation. If it's unsigned, we don't use it to code from.
As for #2, I do not code any procedure without a signed procedure/OP note from the physician, ever. If anything is unclear, I send it back to the physician for clarification. I never guess or just code the best you can. That's just asking for trouble.
Just my opinion.
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