In most cases, the information necessary to assign a specific PCS code is included within the provider’s procedure note or operative report. It is the coding professional’s role to translate the provider’s detailed procedural description into PCS definitions through the coding professional’s knowledge of anatomy, PCS character definitions, and guidelines.
Complete this statement:
When the physician documents “partial resection” the coder can independently correlate “partial resection” to the root operation __________ without querying the physician for clarification.