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Wiki Surgeon documenting CPT codes

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RFoster1

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If a surgeon dictates CPT codes in the heading of his operative report but the documentation in the body of the report causes us to choose a slightly different code, would we need to have the surgeon redictate with the codes we bill with or does it not matter?

TIA!
 
You can only code what is documented. You wouldn't code from the heading of the op note even if your surgeon listed codes in it. The documentation will prevail.

I would show the provider the difference between what he dictated and what codes he thought it was going to be. He can ammend the op note to more clearly identify the steps of his procedure but he should not obliterate the original documentation.

Thanks!
 
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