Wiki OP report vs procedure performed

[chankim]

Are you able to code a procedure that is described in the body of the OP-report but is not listed as a procedure performed section of the report?

 

[LisaAlonso23]

100% yes. Often times, the procedure description is not as detailed as the body of the note.

 

[csperoni]

I definitely agree. As long as the services provided are documented, it should not matter what heading they are under.
Same applies to E/M services. If a clinician puts the exam under HPI heading, you still count it as the exam.