Slice and Dice Your Op Report

By Wendy Grant, CPC


There is no quick way to code an operative (op) report. You must read and reread—think dissection—to be sure your coding reflects all the procedures and diagnoses performed.
Code from the Body of the Report

To code only the “preoperative diagnosis, postoperative diagnosis, and operation performed,” listed at the beginning of the op report, would be incorrect. Additional procedures and diagnoses not shown at the top of the note may be identified in the body of the op report. By coding directly from the body, you can ensure your coding reflects what was actually performed, as well as the diagnoses related to the procedure(s).
Physicians don’t always specify the approach used to perform the surgery. Look for key words to identify the approach. For instance, with abdominal procedures physicians can perform either an open (several centimeter-long incision) or a laparoscopic approach (multiple small incisions). Even if the physician indicates an approach at the beginning of the note, review the body of the op note to verify what he or she did.
Dissect the Procedure Note
The largest section of the op report is the procedure note, which may be a few paragraphs to several pages long. This is where the physician documents the specifics of the procedure and how it was performed. The best way to dissect the note is to use the “slice-and-dice” technique, highlighting relevant information as you go.
The first “slice” in the op note shows the first element of the surgery. A cystotomy involved incising the ovarian cysts to drain them. This is coded with 49322 Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple).
The second “slice” in the op note shows the physician turned his attention to the hydrosalpinx. The portion of the fallopian tube that was filled with fluid was cauterized and removed. This is coded using +58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure).
The third “slice” in the op note discusses the physician removing the appendix. This is reported using 44970 Laparoscopy, surgical, appendectomy. Modifier 59 Distinct procedural service is appended to this code to indicate that an additional organ was excised.
Clear Physician Documentation Is Key

Physicians should clearly document when they perform excisions, biopsies, lesions, removal of foreign bodies, placement and removal of drainage or feeding tubes, internal hardware used as part of repair, grafts, and the type of closure. The closure description should include enough detail to support any additional coding for an extensive repair.
What’s included or bundled? Pretty much anything that has to be done to accomplish the main procedure. The incision (or creation of ports for laparoscopic instruments) is included. The normal closure at the end of the procedure is always included, as well.
The physician should document any complications, as well as any abnormal findings: This is where the physician should document the time for procedures requiring additional work (for example, extensive bleeding or extensive scar tissue). If the surgeon documented significant additional work and/or time, over and above the usual time required to perform the surgery, you may be able to append modifier 22 Increased procedural services to request additional reimbursement.
Regardless of the surgical procedure a physician performs, you should always be on the lookout for certain elements in the documentation. Remember to read the complete op report and don’t code only from the summary or title of the procedure. Using the “slice and dice” technique can help easily identify multiple procedures within one op note.
Wendy Grant, CPC, has been in the coding and billing industry for 30+ years, with 22 of those years in clinic management. She is the accounts receivable manager for Health Management Physician Network, Western Division, and analyzes coding and denials, and provides coding education to maximize revenue. Ms. Grant has been on the AAPCCA Board of Directors since 2009 and served as secretary in 2011. She has been certified since 2002.

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One Response to “Slice and Dice Your Op Report”

  1. Irina says:

    My question about op-reports is if a surgeon dictated that he performed “air fluid exchange” as a procedure in the body but it is not in the header “procedures performed,” does that mean that he/she must include that in the header as well? If so, are there any guidelines or documentation that I can find? If a surgeon dictated a certain procedure in the body it must be also in the header..
    Thank you