At a county hospital, radiology reports a right knee meniscal tear, but the operative report documents arthroscopy of the left knee. Before final coding, what is the most appropriate next action?
Select an answer to reveal the explanation.
Short Explanation
Think of laterality like labeling the wrong shelf in a warehouse — you do not ship until the labels match. When imaging and the op report disagree on left versus right, that conflict is a classic query trigger, not a coin flip for the coder. Get a clear, non-leading clarification before you lock codes.
Full Explanation
Conflicting laterality between imaging and the operative report is a documentation discrepancy that affects both diagnosis and ICD-10-PCS/CPT laterality characters. Facility coding standards and query practice require clarification when the record supports more than one interpretation of which side was treated. Coders should not independently choose the imaging side, code both sides, or default to unspecified when a query can resolve the conflict. A compliant, non-leading query protects coding accuracy and the integrity of the health record.