Coding from certain sections of op note

[hpierce]

I have a question. Are there guidelines documented anywhere that says you can or can't code from certain "sections" of the op note? I know you shouldn't only code from the heading of the note, that you need to read the entire note and I understand that, but I have a note where the physician lists he did a hernia repair ("hiatal hernia repaired posteriorly with single stitch") but the repair isn't mentioned in his description of the procedure. It seems to me like he should dictate an addendum however, this particular physician will want documentation to support my argument. Is there anything that I can show him?

Please help!!
Heather, CPC

[kevbshields]

Information from the entire operative report factors in the coding of the case/services. An addendum would not be necessary, assuming you have enough detail to code from the information in the body of the report. Information does not necessarily need added to the procedure title, as you note, that is not the final determinant in code selection. I find that the body of the operative report carries many more details that impact coding and as a practice, pull diagnoses and services out to report through the codes.

On one hand, you must take the total operative report into consideration when coding; but it is the body or "findings" of the note that have the greatest impact on coding the case.

[twtcpc]

Hi Heather,

I agree with Kevin, the whole note should be utilized when coding for surgical services and really any other procedure and/or visit. I have worked on pain management and have seen multiple physicians put the name of the procedure that they go in intending to do in the header of their note; however, due to complications and/or physical anomolies prevent the intended procedure from being done/completed. They also tend not to specifically state the procedure name in detail, but do describe the process of doing the procedure that was actually completed.

[hpierce]

Thank you both for your responses!