With the 2 new codes available this year – M48.061 and M48.062 – if the provider documents on the patient’s initial office visit that the diagnosis is M48.062 – Lumbar Stenosis with Neurogenic Claudication and then the patient ends up having surgery and the operative report simply says Lumbar Stenosis – is it ok to refer to previous documentation and still code the operative note diagnosis as M48.062 even though the provider did not specifically say …with Neurogenic Claudication in the operative note itself? Thank you in advance!
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