In this episode, Terry tackles a common pitfall in coding and CDI workflows: skipping straight to the Assessment and Plan (A/P) section of an E/M note to determine service level. Are you overlooking key documentation that could support medical decision-making, risk, or time?

She also calls out a frequent habit among surgery coders—coding from the report header instead of the full operative detail. What assumptions are being made based on titles alone? What critical elements might be missed or misinterpreted?

Terry breaks down why accuracy isn’t enough. Coders must be diligent, thorough, and intentional in their medical record reviews and extrapolation processes. Lazy shortcuts can lead to compliance issues, missed revenue, and flawed data.

Tune in for practical insights on how to elevate your coding practices and avoid costly oversights.

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