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Laterality (left or right) is explicitly documented in the record The most specific code supported by documentation is being used The code has been updated if a definitive diagnosis was confirmed after the initial visit Traumatic and non-traumatic codes aren't mixed on the same claim Documentation supports medical necessity for every service billed External cause codes (V00-Y99, Y92) are included where applicable, especially on initial encounters CPT codes align with the ICD-10 diagnosis code Seven checkpoints

Malenfant et al

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