Operative Report Coding Tips

Operative Report Coding Tips
  1. Diagnosis code reporting—Use the post-operative diagnosis for coding unless there are further defined diagnoses or additional diagnoses found in the body of the operative report. If a pathology report is available, use the findings from the pathology report for the diagnosis.
  2. Start with the procedures listed—Read the note in its entirety to verify the procedures listed in the header. Procedures in the header may not be listed correctly, and procedures documented within the body of the report may not be listed in the header.
  3. Look for key words—Key words may include locations and anatomical structures involved, surgical approach, procedure method (debridement, drainage, incision, repair, etc.), procedure type (open, closed, simple, intermediate, etc.), size and number, and the surgical instruments used during the procedure.
  4. Highlight unfamiliar words—Research for understanding.
  5. Read the body—All procedures reported should be documented within the body of the report. The body may indicate a procedure was abandoned or complicated, which may indicate a need for a different procedure code, or to append a modifier.
John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

No Responses to “Operative Report Coding Tips”

  1. Kelly Pratt, CPC, CPC-I, COBGC says:

    We wait for the pathology to be completed for a variety or reasons.
    – We have GYN Oncologists and based on the findings, it could change the CPT and Dx code drastically.
    – MIG (Minimally Invasive Gynecology) docs perform quite a few hysterectomies. If these are done laproscopically this can also change the code and RVUs billed.
    It is so very important to use the post-operative diagnosis(es) not everybody realizes that.

  2. Jeanne Lee, CPC says:

    Dear John,
    If a patient has a bilateral diagnosis for the ears, but the surgeon is operating on the LT side only, don’t you code the diagnosis only for the
    ear being operated on?
    Looking forward to your answer.
    Thank you,
    Jeanne Lee