It should come as no surprise that deficiencies in operative reports may also have an impact on the overall assumptions of a surgeon’s record-keeping. To help our members, we’ll provide some case examples, which have been edited, eliminating dialogue unimportant to the analysis. For each case, we’ve provided the coding expected from the surgeon along with the coding that’s recommended based on the documentation of the procedure provided – since only steps documented can be assumed to have been performed in the operation.
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