AMA CPT® Assistant - 2008 Issue 11 (November)

Coding from a Procedure Report (November 2008)

November 2008 pages 7-9 Coding Communication:Coding from a Procedure Report Coders often ask whether there is an easy way to code from a procedure report. The answer is an emphatic "no;" however, there are steps one can take to make the process more logical. One must read the report, often more than once, to be sure that the coding reflects all of the procedures and diagnoses contained in the report. Many coders assume that coding the preoperative diagnosis, postoperative diagnosis, and operation performed as listed at the beginning of the procedure report would be correct. This is not...

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