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Coding procedural reports

  1. #1
    Exclamation Coding procedural reports
    Medical Coding Books
    Quick question.....with procedural reports, do you go by the body of the report or the procedure performed headings? There has been some conflict in my office since the procedure performed listed isnt always like what is described in the body of the details! (ex: the procedure listed is: excision of 2.5 cm trunk lesion with complex closure.....but the discription of the procedure only shows details of a layered closure--> so is it 12031 or 13100?)

  2. #2
    Milwaukee WI
    Default Code Body of Report
    When there is a discrepancy between the title and body of the report I, FIRST, go back to the surgeon and ask for clarification and an addendum if needed.

    I always code based on the body of the report NOT the title.

    F Tessa Bartels, CPC, CEMC

  3. Default
    I agree with FTessaBartels. I don't know about your transcription system, but the titles of the reports that come through our system isn't always correct. I would always go by the body of the note. That would be the most accurate. And if there is a discrepancy, you can go to the surgeon.


  4. #4
    Louisville, KY
    The body of the report is where coding is correctly pulled from. Queries are a good idea if there's actually a requirement for provider clarification. Otherwise, I'd go with the body--the title is just that, a title.

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