Revenue Cycle Insider

Highlighting procedures from the notes will help you code as you go.

Tyler Griffeth’s, MOL, CPC, CPRC, HEALTHCON 2025 presentation, “Coding Complex Operative Reports: Tips and Tricks from an Expert,” offered valuable tips for finding trustworthy information online for coders of all experience levels while decoding operative reports.

Read on to learn more about how to access these valuable tools already at your fingertips.

Recognize the Language of Your Provider

“The first thing to note in an operative report is to recognize what’s fluff. What doesn’t really matter to us? There are little pieces of fluff throughout the operative report that a doctor will state merely because [they] always state that, because they always do it,” said Griffeth. The example he gave is the usual information about the patient being placed in a supine position and anesthesia being administered.

Griffeth stated that the more you code for the same physicians, the more you will become familiar with their note style, and you can begin to skim over this language. He warns not to completely skip what may appear to be mundane information, however, as useful information for coding may be hidden within it from time to time.

How to Read the Giant Scary Note

Next, Griffeth told the audience it was time to begin reading “the giant scary note,” or the more complicated information found in the operative report.

“If you don’t understand, you look it up,” said Griffeth. “But where do you look, and who do you trust, and why do you trust them?” he asked. He recommended looking for trustworthy sources like AAPC, AMA, Centers for Medicare & Medicaid Services (CMS), and Palmetto GBA for accurate information, just to name a few. If you are drawing a blank on where to even start, and you feel the need to start with Google, he had tips for that, too.

Use Google in a Smarter Way

A bit of information everyone in the audience can surely benefit from, was when Griffeth explained eight tips to “Google Like a Pro” to help you find the specific information you are looking for online:

1. Use quotation marks around your search terms

• Google will search for webpages containing that exact phrase.

2. Limit to news

• If you are looking for standards-based news articles that contain your search term, narrow your initial search results by clicking the tab labeled “news.”

3. Use basic Boolean operators

• Use AND (all uppercase) when you’re searching to find results that contain more than one exact search term. Example: “Cardiac” AND “General surgery.”
• Use OR (all uppercase) when you’re searching to find content containing only one of your search terms. Example: “Search term 1” OR “Search term 2” OR “Search term 3.”

4.  Use parentheses to group operators

• You can use parentheses to order the search operations the way you would in a mathematical equation. To search for only one of two search terms AND a third term, you would search: (“Search Term1” OR “Search Term2”) AND “Search Term3.”

5. Narrow the time frame

• When you get results for a search, click on “Tools” and then “Any time.” In the dropdown box, you’ll be able to choose from results in the past hour, 24 hours, the past week, and so on.

6. Search a specific website

• Limit your results to one specific website by adding “site:WEBSITENAME.com” to the search terms. For example: site: aapc.com “general surgery”

7. Search one section of a specific website

• You can also search for a specific subdomain or subdirectory on a particular website. For example, to quickly search Facebook (a website) for groups (a subdirectory) that use the exact phrase “medical coders,” your search bar should look like this: site:facebook.com/groups “medical coders”

8. Use a minus sign to exclude results you don’t want

• Just type the minus (-) sign to remove particular search terms or websites from your search. For example, if you wanted to search Facebook groups for the term “medical coders” but wanted to exclude the phrase “feet,” you would search: site:facebook.com/groups “medical coders” - “feet.” Make sure you put a space on either side of the minus sign for this feature to work.

Use These Tips for the Visual Learners

If you are a visual learner and drawing out procedures will help you better understand the complex notes from your practitioners, go ahead and try that. Griffeth and his colleagues started out trying this method when they were confused by the procedures listed in surgical notes in the beginning of their coding careers. He shared examples of Post-its and whiteboard drawings with the audience members.

“You will be shocked at how doing this even once, especially with a typical note you are used to seeing, how drawing this out, really helps. It will really help with your understanding,” said Griffeth.

Analyze These Additional Tips and Tricks

If you are still confused as to what procedures were performed during the surgery, Griffeth suggests looking at the different sections of the notes to answer some questions like:

• What does the doctor think they did?
• Why was the surgery performed?
  • Was it to relieve a symptom of a disease?
  • Was it to prolong the survival of the patient?
• What was the preoperative diagnosis?
• What was the postoperative diagnosis?
• What procedures were actually performed?

Make a list if you need to from the notes. “Once you start to confirm from the notes which procedures were performed, start highlighting those with a highlighter and writing the codes next to those procedures,” said Griffeth.

Griffeth also reminded the audience to pay attention to parenthetical information in your coding books. This will help you eliminate unnecessary information and coding errors as you review the operative report. “Remember, a lot of parenthetical notes will give you advice. For instance, if you’re coding [A] don’t also code [B]. Pay attention to the Includes and Excludes notes,” he explained.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC