A wrist fracture is documented in a physician office note without laterality. Which query approach is appropriate?
Select an answer to reveal the explanation.
Short Explanation
Missing left/right is fixable—but not by putting the answer in the question. Offer the real choices, include what you see in the chart, and let the provider pick. That is a clean laterality query.
Full Explanation
When laterality is required for specificity and is missing, a compliant query presents reasonable options (for example left, right, bilateral, and undetermined/cannot be determined) along with relevant clinical indicators from the record. Leading yes/no prompts that assert a side are noncompliant. If laterality cannot be obtained, coders use the appropriate unspecified code rather than inventing a side.