Discrepancy between Procedure Title and Documentation Details
Question:
If the details of a procedure documentation do not match the listed procedure/operation that was planned, which procedure code should be selected?
Answer:
CPT codes are always chosen based on the documentation within the detailed portion of an operative record. If the details within the body of the report do not match the “procedure title” listed in the beginning of the operative report, the provider should be queried for clarification and a possible addendum to the record if necessary.
*This response is based on the best information available as of 1/16/25.