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?

While abstracting an inpatient orthopedic case, conflicting laterality between the history and physical (right knee) and the operative report (left knee) is a query opportunity: seek clarification before final coding. Site accuracy at a public hospital protects patients from wrong-site coding errors and protects claim integrity for civic payers. Coding both laterality values so the claim covers either side fails and creates impossible dual-site reporting without clinical support. Ignoring the conflict and coding the side that yields the higher-weighted DRG fails as payment-driven selection. Defaulting to the H&P because it was signed first fails; document chronology does not automatically resolve operative site conflicts when the operative narrative disagrees. Exam caveat: laterality conflicts require clarification, not dual coding, payment preference, or first-signed defaults. Operational check: stop the municipal orthopedic abstract, query the surgeon to confirm the operative site, update documentation as authenticated, then assign laterality-dependent diagnosis and procedure codes. Escalate recurring laterality mismatches to OR safety and documentation improvement leaders so public surgical services reduce wrong-site documentation risk.