Nicoletti Notes October 2025
Published on October 2nd, 2025

We’ve updated CodingIntel’s Telehealth article again. We’ll keep you up-to-date with the latest Medicare rules.

Medical coding is a high-stakes discipline as accuracy affects reimbursement, compliance, and the overall health of the revenue cycle. Just as a reminder, here are three frequent mistakes to watch out for—and how to avoid them.

Coding from the Heading of an Operative Report
It’s tempting to rely on the procedure title at the top of an operative report, but this shortcut can lead to incorrect coding. The procedure listed in the heading is often a general descriptor or is the procedure listed at the time of scheduling. This may not reflect the full scope or the actual procedures performed.

Best Practice: Always read the body of the operative report. Look for specific techniques, anatomical sites, and any additional procedures or use of devices that may affect code selection.

Defaulting to Hospital ICD-10-CM Codes in Shared EHRs
When office and hospital visits share an electronic health record (EHR), it’s easy to default to hospital-assigned diagnosis codes. But these codes may not reflect the provider’s intent or the clinical context of the outpatient visit.

Best Practice: Review and validate diagnosis codes for each encounter. Ensure that the codes used in the office setting are appropriate and supported by documentation from that specific visit.

Skipping to the Assessment and Plan for MDM or Time-Based Coding
In the rush to calculate either medical decision making (MDM) or time-based coding, some coders jump straight to the Assessment and Plan section of the progress note. But without reviewing the history and exam, you may risk missing critical context that affects medical complexity and time justification.

Best Practice: Read the entire note for context and comprehension. The history and exam often contain clues about comorbidities, risk factors, and patient concerns that may elevate the level of service.

Avoiding these pitfalls helps to ensure accurate coding, supports proper reimbursement, and strengthens compliance in coding and billing, where precision matters. Taking the time to verify and validate documentation when choosing a level of service is time well spent.