Muscles that attach to bone or soft tissue without a tendon use a broad sheet of connective tissue called an aponeurosis

Two days after a call, you realize that you forgot to document that you checked a patient's pupils before the patient refused further treatment and signed a refusal form. Which of the following actions is your best course of action?

a. Complete a new refusal form and include the additional information. b. Add an addendum to the report that contains the correct information, the current date, and your signature. c. Report the error to your patrol director and have him/her take care of it. d. Don't worry about it because it did not seem to matter to the patient.

The coder is not required to query the physician when the correlation between documentation and defined ICD-10-PCS terms is __________

a. clear b. invalid c. medically necessary d. undefined