While abstracting an inpatient orthopedic case, the history and physical documents a right-knee procedure indication, but the operative report describes the left knee. What should the coder do?
Select an answer to reveal the explanation.
Short Explanation
Left versus right is not a coin flip. When the H&P and op report disagree on side, stop and clarify—that conflict is exactly what abstraction is supposed to catch. Guessing or dual-coding the wrong side just builds a bad claim.
Full Explanation
Accurate abstraction includes identifying discrepancies that block reliable code assignment. Conflicting laterality between the history and physical and the operative report must be resolved through clarification with the responsible provider rather than selecting a side based on payment or document order alone. Coding proceeds only after the conflict is cleared.