Hi all!
If the provider's E&M note references a diagnosis from a radiologic procedure but doesn't specify site &/or laterality in his E&M note, can a coder review the radiology report in the MR in order to code to the highest specificity (site/laterality) or MUST the E&M documentation stand-alone resulting in coding as "unspecified"?
Example:
E&M note states: osteopenia (M85.80 unspecified code)
Radiology report states: osteopenia of the right hip (M85.851)
TIA for your guidance!
If the provider's E&M note references a diagnosis from a radiologic procedure but doesn't specify site &/or laterality in his E&M note, can a coder review the radiology report in the MR in order to code to the highest specificity (site/laterality) or MUST the E&M documentation stand-alone resulting in coding as "unspecified"?
Example:
E&M note states: osteopenia (M85.80 unspecified code)
Radiology report states: osteopenia of the right hip (M85.851)
TIA for your guidance!
