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Thread: coding from operative notes

  1. #1

    Question coding from operative notes

    AAPC: Back to School
    Please clarify this issue for me. Also please offer any resources I may site reagrding this question. Many of our physicians feel that we can code from the "Procedures Performed" or "Conclusion" section of their note although no interpretation may be given in the body of the note or in the description of the procedure they performed. Those of us in our department, all CPC's, agree that you can't code form those sections that the information must be provided in the body of the note. Does anyone know a good site or source we can provide to the physicians to show they must dictate in the body (procedure description) for it to be coded?

  2. #2
    Join Date
    Apr 2007
    Jefferson County


    It is my understanding that you can only code what the procedure is and not on the assumption on what the doctor did if it is in their notes. If they didn't do it then you can't code it. What is in the operative report is what you code the actual procedure.

  3. #3

    Default A detailed procedure note is a must!

    It should go without saying that your physicians need to explain everything they did during a procedure in order for you to bill for it but I currently can't find a resource you can show them that spells it out so clearly.

    Maybe you should try the CMS website or maybe AMA. If I find anything, I will let you know.

    Lisi, CPC

  4. #4


    Thank you for the responses. Yes it does go without saying docs are to dictate everything they do in the body of the note. I was able to locate a source so I wanted to share. The information can be found in the November 2008 CPT Assistant. Clearly states coding must be done from the body of the op note and not from the procedures performed because it may not have been performed.

  5. #5
    Join Date
    Apr 2007
    Detroit, MI 31312


    I agree with coding from what's actually dictated in the report, Our physician's also wanted us to code that way a few years ago, we were instructed to do so against we we believed. Anyway, few months down the road internal audits were done and to our findings procedures were missed, money was lost. After bringing that to our Docs attention, they were pleased with the way we wanted to code, and how it actually should be done.
    Stephanie Phillips, CPC-H

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