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The Future of Knee Repair - February 2016 - Subscribe to Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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Coders and billers should never assume a condition without proper documentation or clari- fication from the physician. It's a common problem in a lot of facilities. The coder reviews the op notes and sees that the doc failed to document a key com- ponent of the procedure. He sends her a message saying, "You failed to establish the con- nection between hypertension and heart failure in the notes. I'll go ahead and change it, if that's correct." The coder could be right, but the doc may resent his tone and ignore or delay response. Instead, the coder should send a message simply saying he wanted to clarify whether there was a connection between the hypertension and heart failure. It's to the point, requires a yes or no answer and doesn't seem like he's pointing fingers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