Yes I agree with Pam. It is always good (even right) to code based on the detail description of the procedure since the header documentation will give you information just about the procedure whereas the detailed description gives you the whole picture and also it guides you on any alteration (both more than planned or less than planned) of services provided.
As Pam said, any conversion of approach in cholecystectomy cases (Laparoscopic to Open) or additional services during cholecystectomy ( "with cholangiogram" ) or Vaginal hysterectomy (with documentation of weight of the uterus and information on tube removal) or approach in myomectomy cases (vaginal / abdominal), Level of toe amputation (Interphalangeal vs Metatarsophalangeal) or Complexity of the abscess drainage (simple vs complex) etc....
Additionally, we can collect some diagnosis information from the body of the report.
So, when we have many benefit of detailed notes, why should we miss them out?
Thanks,
Vernon Kreiss