Op Note AI: Validation Examples

Partial medial meniscectomy plus patellofemoral chondroplasty, both compartments documented.

Per CMS NCCI 2026, 29877 is not reported with knee arthroscopy codes 29866 to 29889; since 2020, 29880 and 29881 include chondroplasty in the same or a separate compartment. Medicare G0289 applies only to loose or foreign body removal from a different compartment. Payer specific: some commercial plans differ.

ACL reconstruction, medial meniscectomy, chondroplasty.

Published NCCI guidance bundles chondroplasty into ACL reconstruction regardless of compartment; the meniscectomy stays with modifier 51.

Meniscectomy with limited synovectomy of the same knee.

NCCI: 29875 is a separate procedure code and is never reported with another arthroscopic procedure of the same knee.

Cuff repair, biceps tenodesis, subacromial decompression, extensive debridement in a different area.

29826 is an add-on to cuff, claviculectomy, tenodesis, labral, and SLAP work; 29823 survives only with a documented different area of the same shoulder.

SLAP repair plus subacromial decompression.

The decompression add-on attaches to SLAP repair and never takes modifier 51.

Note documents fixation of all three malleoli.

Exclusive family: the trimalleolar code replaces the bimalleolar code rather than stacking with it.

Cephalomedullary nail for an intertrochanteric fracture.

Single fracture fixation code, valued at 17.73 from the 2026 file.

Primary TKA.

Valued at 19.11, the 2026 figure; hip and knee primaries were equalized in the 2021 revaluation.

Acetabular and femoral component revision.

Both-component revision is a single code at 29.52, not two codes.

Displaced femoral neck fracture treated with hemiarthroplasty.

One code covers open reduction or prosthetic replacement of the femoral neck; the 2026 file values it at 14.76.

Colonoscopy with biopsy plus EGD with biopsy.

Different endoscopic families in one session are each reportable; the lesser-valued scope takes modifier 51.

Endoscopic release, both wrists; open code also mentioned.

The endoscopic code excludes the open code for the same release, and bilateral surgery takes modifier 50 with 150 percent credit.

ACDF at two interspaces with plate, cage, and structural allograft.

Add-ons stack on the primary in value order and never take modifier 51; the set totals 48.09 wRVU.

Displaced femoral neck fracture treated with hemiarthroplasty.

27236 covers open treatment of a femoral neck fracture including prosthetic replacement; the elective hip arthroplasty codes do not apply to fracture care.

Removal of a deep plate and screws from a healed fracture.

Deep implant removal is 20680 at 5.81; a superficial pin or wire is 20670 at 1.79. One code per fracture site regardless of the number of screws, and a staged removal planned at the index surgery takes modifier 58.

Cholecystectomy with intraoperative cholangiography.

The cholangiogram upgrades the code rather than adding one; valued at 11.18 from the 2026 file; the plain chole is 10.21, so documenting the cholangiogram is worth about one wRVU.

Open ventral hernia repair with mesh placement.

The 2023 CPT revision deleted 49560 to 49590 and mesh add-on 49568. The current family is 49591 to 49596 for initial repairs, sized by defect, with 49613 to 49618 for recurrent; mesh is included when performed.

One stable chronic problem on a continued prescription, nothing else.

Two of three columns set the level and the second highest here is low: one stable chronic problem is low complexity even with prescription management at moderate risk.

Hypertension and diabetes, both stable, both medications continued after review.

Two or more stable chronic conditions reach moderate problem complexity; with prescription management this is a defensible level 4, and the stated return plan adds G2211.

Knee injection today plus diabetes managed separately.

A modifier 25 procedure day excludes G2211 on ordinary visits; the level rests only on the diabetes because assessing the injected joint is part of the injection. CMS preventive service exceptions such as the AWV are the carve out.

Patient returns solely for the planned injection.

The only documented problem is the one treated by the procedure, so no separate E/M was coded; distinct work on a different problem is what earns modifier 25.

Simple stable problem, but 33 documented minutes of counseling and education.

MDM alone supports only a low level, but 30 to 39 documented total minutes supports 99214 on time; one sentence with real minutes changes the level.

Suspected giant cell arteritis with transient vision loss; urgent workup; hospitalization considered.

High problem complexity plus high risk once hospitalization is considered and documented; without that sentence the same chart is an airtight 99204.