By Mary LeGrand, RN, MA, CCS-P, CPC
Although dictation of operative notes might seem straightforward, many surgeons fail to include enough information to enable proper coding of knee procedures not related to joint reconstruction. For example, documentation differentiating open and arthroscopic procedures is often missing; incorrect or nonspecific diagnosis codes may be used; and CPT, G codes, and modifiers may be used incorrectly.
Operative note coding tips
The following tips will help surgeons dictate a clear operative note.