Read the Whole Note
by John Verhovshek, MA, CPC
As a coder, you should always review the provider’s entire progress or operative note to be sure no reportable services are missed. Improper code selection also may result if you code from documentation headers instead of reading the note in its entirety.
For example, the operative report header report may list the “expected” procedures, but the body of the note may record a more extensive or entirely different procedure due to unforeseen circumstances. Or, the body of the note may contain diagnostic information that helps the coder to select a more precise diagnosis code.