Seven Steps to Correctly Code Surgeries

It’s all in how you dissect the operative report.

Many coders struggle with coding operative reports because there are so many guidelines and policies that affect code selection. The process is easier when you break it into seven steps:

Review the header of the report.
Review the CPT® codebook (start in the Index).
Review the report/documentation.
Make a preliminary code selection.
Review the guidelines (for the preliminary codes).
Review policies and eliminate the extras.
Add any needed modifiers.

These seven steps will ensure all the factors that may affect code selection are accounted. Let’s look at an example, and walk through the steps together.
Step 1 Review the Header of the Report…

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View all Articles by: Melissa Clark, CCS-P