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Medical Record Documentation

Vicki Posted Thu 12th of November, 2015 10:08:51 AM

Does the provider/surgeon have to list the actual CPT code and ICD 10 code in the operative report as long as his documentation states the procedure descriptions and diagnosis descriptions that he is performing in the operative report?

SuperCoder Answered Fri 13th of November, 2015 04:42:21 AM

No the surgeon does not require to list CPT and ICD-10 code in the operative report because a coder need to report the appropriate CPT and ICD-10 code for the operative report.


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