I’m coding a surgery from from procedure report (and hasn’t been dictated yet). They did not indicate whether the ostectomy was partial or complete. Is there a default to code when they don’t give you the information (like in icd-10) or would I need to request this information before I can code appropriately? The following is what’s on the procedure report:
excision and application of wound vac 6×5
ostectomy of the 4th and 5th metatarsal and cuboid
excision and intermediate closure 4cm lateral foot
anesthesia: MAC
diagnosis: wound to the right foot
Thanks for the help!