AAPC - Back to school
Results 1 to 4 of 4

Thread: Coding procedural reports

  1. #1
    Join Date
    Apr 2007
    orange, ca

    Exclamation Coding procedural reports

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    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. #3


    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
    Join Date
    Apr 2007
    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.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

Similar Threads

  1. Help with IP Procedural Coding
    By jedcoder17 in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 07-04-2015, 08:30 AM
  2. 2012 Procedural Coding Expert
    By tldixon@mokancomm.net in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 02-27-2012, 07:52 AM
    By EverythingCoding in forum Medical Coding General Discussion
    Replies: 7
    Last Post: 01-12-2010, 07:21 AM
  4. Procedural Coding Professional
    By cbheusman in forum Orthopaedics
    Replies: 2
    Last Post: 02-02-2009, 07:12 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.