The operative report header lists a laparoscopic-only procedure, but the surgeon’s narrative documents conversion to an open approach. How should the coder resolve the approach for coding?
Select an answer to reveal the explanation.
Short Explanation
Headers are the cover; the narrative is the story. If the surgeon wrote that they converted to open, trust that story over a leftover “lap only” label on the top of the page.
Full Explanation
When an operative report header conflicts with the surgeon’s narrative, narrative operative details that clearly document conversion to open generally control for approach resolution. Coders should not prefer an incorrect header, invent concurrent approaches, or delay coding solely for a cosmetic header rewrite when the body of the report already documents the conversion.