1. Patient & Procedure Verification

✔ Correct patient (name, DOB, MRN)
✔ Date of surgery
✔ Primary surgeon + assistants (PA, NP, RNFA, resident)
✔ Preoperative diagnosis
✔ Postoperative diagnosis
✔ Procedures performed (as documented in the op note header)
✔ Compare header vs body → Code the body if there is disagreement

2. Approach & Surgical Access

✔ Open, percutaneous, endoscopic, laparoscopic, robotic, arthroscopic, microsurgical?
✔ Side or laterality (right, left, bilateral)
✔ Incision type/location & portals
✔ Conversion? (lap → open, endoscopic → open)
→ Important because conversions often change CPT coding

3. Anatomy & Structures Treated

✔ Exact anatomical site
✔ Laterality
✔ Number of structures (e.g., nerves, vessels, vertebral levels, tendon repairs)
✔ Full anatomical detail

• Joint(s)

• Level(s)

• Quadrants

• Organ(s)

• Vessel(s)
  ✔ Depth (superficial vs deep)
  ✔ Layers involved (skin, fascia, tendon, muscle, bone)

4. Surgical Technique Details (Critical for Correct CPT Selection)

✔ What EXACTLY did the surgeon do? Look for verbs:

• Excised

• Released

• Removed

• Debridement (selective vs non-selective; depth)

• Repaired

• Fused

• Stabilized

• Placed

• Explored

• Dissected

• Drained

• Ablated

• 2019" data-end="2028">Ligated

✔ Important technique elements:

• Instrumentation used

• Dissection method

• Approach route

• Imaging used

• Fluoroscopy, ultrasound, CT guidance (intraoperative)

• Fixation devices or implants

• Grafting (autograft, allograft, synthetic, structural)

• Layers of closure

• Extent of dissection or tissue removal

• Combined or staged procedures

5. Implants, Devices, Hardware & Foreign Bodies

✔ Identify:

• Plates, screws, rods, cages, grafts, anchors, prostheses, pumps, ports

• Removal vs insertion vs revision vs replacement
  ✔ For device-dependent codes → confirm where the device was placed, how, and what bone/tissue it crosses or pierces
  ✔ Document size, type, and number when relevant

6. Imaging & Guidance (Do NOT assume — only code if documented)

✔ Fluoroscopy
✔ CT
✔ Ultrasound
✔ Endoscopic visualization
✔ Navigation systems (computer-guided, stereotactic)
✔ Intraoperative monitoring (IONM)

Procedural rules:

• Guidance must be performed AND documented to code it

• Some codes include guidance → check CPT®

7. Specimens & Pathology

✔ What tissues were removed?
✔ Sent to pathology?
✔ Number of specimens?
✔ Was the removal incidental or therapeutic?

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8. Complications (Intraoperative Only)

✔ Bleeding requiring control
✔ Incidental enterotomy repaired
✔ Hardware malfunction
✔ Iatrogenic fracture or tissue injury
→ Coders DO NOT code complications unless they require additional documented work.

9. Bundled vs Separately Reportable Work

✔ Check NCCI edits
✔ Is the procedure:

• Inclusive/bundled?

• A component of the primary procedure?

• Integral to the approach or exposure?
  ✔ Do NOT separately code:

• Wound closure

• Positioning

• Local anesthesia

• Typical dissection/exposure

• Fluoroscopy when built into the CPT code

✔ Do code:

• Distinct procedural sites

• Separate anatomical structures

• Staged or separate surgeries

• Different approaches

• Significant additional work (modifier 22)

10. Compare the Header, Body & Closing Summary

✔ The body always determines coding
✔ Verify the procedure list matches the narrative
✔ Ensure everything coded is fully supported with clear, specific documentation

11. Modifier Assessment

✔ Laterality modifiers (RT, LT, 50)
✔ 59/XS/XU for distinct work
✔ 22 for increased complexity (must be well-documented)
✔ 51 for multiple procedures
✔ 58 for staged/related
✔ 78 vs 79 for returns to OR
✔ AS for PA involvement (Medicare)

12. Final Checks Before Coding

✔ Medical necessity supported?
✔ All anatomy/approach documented?
✔ All implants/devices accounted for?
✔ All bundle rules checked?
✔ All guidance documented if billed?
✔ All diagnoses support the procedures?
✔ Ensure the op note supports every code, line by line