CPT and ICD-10-CM Codes in Operative Notes

Question:

What is KZA’s perspective when a surgeon documents the CPT codes within the clinical operative note? 

Answer:

KZA discourages using CPT and ICD 10 codes within the operative notes. While documenting details of each procedure is key within the operative report (both the header and within the body of the note), adding CPT and ICD 10 diagnosis codes creates an issue if the coding is incorrect. The operative report is part of the legal medical record, and payors may question the accuracy and validity of the entire report if the codes documented within the record are different than the codes billed. For this reason, we advise against documenting the specific CPT and ICD 10 codes within the operative report to prevent other denial and stall tactics. 

*This response is based on the best information available as of 6/20/24.