An operative report documents a left-knee arthroscopy, while the consent and history and physical document the right knee. What is the coder’s correct next step?
Select an answer to reveal the explanation.
Short Explanation
Left in the op note, right on the consent and H&P—hit the brakes. Site of surgery is too important to guess. Clarify the laterality, then code.
Full Explanation
Laterality conflicts among consent, history and physical, and operative documentation must be reconciled before procedure coding. Selecting a side based solely on one document without resolving the conflict risks incorrect site coding. Unspecified laterality is not an appropriate workaround when conflicting specific sides are documented.