Code from the Operative Note
By Brenda Edwards, CPC, CPB, CPMA, CPC-I, CEMC
Have you ever planned a project, and when you begin you find that it isn’t going to work out as planned? You run into a snag that make it take twice as long, or maybe you find that you can’t complete the project for an unseen reason. Let’s say you left a note telling your family you were going to run to the store to pick up deck cleaner to get ready for the summer, and you’ll be right back! You get to the home store and find there are all kinds of variables to go with that deck cleaner – do you get the deck pre-wash? What’s the method of washing – do you scrub it or use a pressure washer? Is the product for treated or untreated wood?
That short trip just turned into a more time consuming trip.
The same holds true for surgery. The plan may be to perform a laparoscopic repair but, upon entering the body, there is more to repair, or the procedure may need to be converted to an open procedure to accomplish it.
The entire operative report should be reviewed prior to assigning codes. The preoperative diagnosis should not be used as the definitive diagnosis, and in fact, may not be reflected in the postoperative diagnosis. The postoperative diagnosis is what the surgeon confirmed to be performed during the procedure. “Procedures performed” is a preview of what should be found in the operative report. Keep in mind that anything coded must be documented in the body of the report.
The operative note is the full report of what the surgeon performed during surgery. What do you do if the “procedures performed” indicates something that is not included in the body of the operative report?
Query the provider. The surgeon is the only one who can tell you exactly what happened during an operation. A surgeon may perform the same procedure quite frequently but that doesn’t mean that the operative report will always be the same. There are subtle nuances that can occur and must be documented, such as:
- Procedure takes longer than expected or is more complicated than usual
- These situations might need a modifier to indicate the extra work involved.
- Example: Dense adhesions that required a great deal to time and effort (both of which are documented) than the normal procedure would involve.
- Unable to perform what was planned
- Perhaps the surgeon discovered something that prevented the complete surgical plan from occurring
- Example: A full colonoscopy was planned but due to the structure of the colon (appeared to be twisted), the scope could not be guided through the entire colon.
- Unexpected findings upon entering the body
- On the flip side, things could be worse than what testing showed before surgery and additional procedures are performed.
- Example: Planned procedure is laparoscopic cholecystectomy. Once the abdomen was inflated and entered, the surgeon discovers the common bile duct is blocked and cannot be cleared through the laparoscopic approach. The procedure is converted to an open procedure and a new connection is made between the common bile duct and the small intestine to ensure passage of the bile.
You can’t stop reading at the end of the procedure; the operative report will also include information on the closure, drains, packing, etc., as well as the disposition of the patient when transferred to recovery. The complete story is told when you read the entire operative report. Reading only the header of the operative report could be compared to reading the back cover of a novel; you can get the highlights but the details won’t be clear until you read the entire novel.