Orthopedic Coding Alert

Question: My doctor [regularly] leaves part of the procedure out of the heading. For example, Jane Doe, DX: C5-6 discectomy with fusion of allograft. In his details of the surgery, he also plated the patient. I have been making him do an addendum adding this to the heading. Also, he will have other diagnoses in the history and physical that I use, but they are not on the operative note. I also make him change this. Am I correct in requiring this information?

New Jersey Subscriber

Answer: Having the procedure listed in the heading will not make or break you as far as compliance and audit liability, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. If you have billed for the service, it must be clearly and specifically documented in the body of the operative report, no matter what is listed in the heading. On a realistic level, any time the operative report has complete information in all applicable areas, the chances of miscoding a procedure are reduced.