The Surgeon vs. The Coder: Why You're Probably Losing RVUs and Don't Even Know It

Last reviewed: June 2026

Let me start by saying something that may surprise you.

The coder is not your enemy.

In fact, most coders are trying very hard to do the right thing.

The problem is that many surgeons have absolutely no idea what happens after they sign an operative note.

They dictate the note.

They sign the note.

They move on to the next case.

Then six months later they wonder why their RVUs seem low.

What Happens After You Sign the Note?

Many surgeons imagine their operative note flying directly to Medicare on the wings of a bald eagle.

That's not how this works.

After you sign your note, someone else has to interpret what you wrote.

That person is usually a coder.

The coder wasn't in the operating room.

The coder didn't see the adhesions.

The coder didn't struggle through the hostile abdomen.

The coder didn't spend an extra hour dissecting scar tissue that looked like it was installed by a concrete contractor.

All they have is your note.

If your note doesn't clearly describe the work, the coder cannot code the work.

The Most Expensive Sentence in Surgery

Here is the sentence I see all the time:

"Dense adhesions were encountered."

That's it.

Congratulations.

You just documented absolutely nothing.

Every surgeon has seen adhesions.

The question isn't whether adhesions existed.

The question is:

How much additional work did they create?

Instead, document:

"Extensive dense adhesions involving multiple loops of small bowel required approximately 45 additional minutes of meticulous adhesiolysis beyond what is typically required for this procedure."

Now the coder has something useful.

Now an auditor has something useful.

Now a payer has something useful.

Coders Cannot Read Your Mind

I once heard a surgeon say:

"The coder should know what I meant."

No.

The coder should code what you documented.

Those are very different things.

If your operative note says:

"Complex ventral hernia repair."

That is not a CPT code.

That is not a modifier.

That is not documentation.

That is an adjective.

The coder still has to determine what procedure was actually performed.

Your Best Friend Might Be the Coding Department

One of the smartest things a young surgeon can do is meet with the coding team.

Buy them lunch.

Ask questions.

Learn what they look for.

Find out why claims get downgraded.

Find out which documentation deficiencies repeatedly create problems.

Most surgeons spend more time choosing a new laparoscopic grasper than they spend understanding how their cases are coded.

That's backwards.

Audit Yourself Before Someone Else Does

Every surgeon should periodically review:

• Cases performed
• CPT codes submitted
• CPT codes ultimately billed
• Modifier usage
• Denials
• Appeals
• RVUs assigned

You may be shocked by what you find.

Many physicians assume that because a procedure was performed, it was coded correctly.

That assumption is often wrong.

The RVU Leak Nobody Talks About

Most surgeons aren't losing money because they forgot how to operate.

They're losing money because nobody taught them how documentation, coding, billing, and reimbursement actually work.

The operating room is only part of the job.

The note matters.

The coder matters.

The claim matters.

And if you don't understand the process, somebody else will define your work for you.

Usually at a discount.

Final Thought

Your coder is not your enemy.

Your incomplete operative note is.

The next time you're tempted to write:

"Dense adhesions encountered."

Ask yourself one question:

If I were the coder reviewing this note six months from now, would I know what actually happened?

If the answer is no, you probably haven't finished documenting the case.