by Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
October 20th, 2014
When determining the type of approach taken in a surgical procedure, it is important to review not only the title of the report but also the body of the report to locate the method used.
Somewhere in the body of the report, and always preferably in the title, scope, endoscope, endoscopy or whatever the type of scope used should be stated. This information is vital to coders and insurance companies for claims coding and processing so if the equipment used isn’t clearly stated you may want to request your surgeon correct the report by adding an addendum.