August 19, 2021

Question:
I’ve been dictating CPT codes in the operative note so that my coder knows what to bill. Recently, we had an insurance company call us out because the codes we billed were not the same as the codes in the operative note. Now I am not sure what to do. What is your advice?

Answer:
KZA has long been a proponent of not documenting CPT codes in the operative note. As you’ve experienced, it is a compliance issue when the codes documented in the formal, legal medical record are not the same as those billed. It is best to find another way to communicate coding information with your coder or billing office. Many surgeons send a secure email to their coder or have a charge capture tool (e.g., an app they use).

*This response is based on the best information available as of 08/19/21.