What is the first step when coding a surgical procedure?

The first step when coding a surgical procedure is to review the operative report thoroughly. The operative report contains critical information about the surgical procedure performed, including details such as the type of surgery, the techniques used, the findings, any complications encountered, and specific services provided.

Understanding this report is essential because it lays the foundation for accurate coding. Coders need to capture every detail from the operative report to ensure that the coding reflects what was actually done during the surgery. By doing so, coders can select the most appropriate CPT codes that correspond to the procedure performed.

While consulting a coding manual, checking for modifiers, and verifying patient insurance details are also important aspects of the coding process, they come after the thorough review of the operative report. Without that initial understanding of the procedure, it would be challenging to accurately determine which codes are relevant or to apply any necessary modifiers appropriately.