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While most surgeons document the surgical procedures they perform in your facility with the utmost precision, there may be times when your coder needs clarification or additional documentation from the surgeon before she can assign the proper codes. When there's conflicting, incomplete or ambiguous information in the operative report, you must ask the physician to verify the procedure performed and get any written clarification in the form of an addendum. The official name for this is a "physician query." What it really means is, "Doc, we need you to clarify exactly what you did."
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