If the provider documents in their note that a procedure was performed, for example they froze 10 warts; can the coder enter the procedure code or does the provider need to have the order entered for that procedure in order to code it?
I have situations where the provider will enter 17110 x10 – which obviously is incorrect – can I change that w/o the provider re-entering that order?
I’m being told that if the procedure is documented in that clinic note, then we can adjust/add the CPT entries to match what is performed. Which makes sense, but at the same time I have doubts.