Operative Report Coding Tips
- 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.
- 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.
- 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.
- Highlight unfamiliar words—Research for understanding.
- 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.