Dissect an Operative Report

Documentation is your first line of defense for coding and claims payment.

The operative report is perhaps the single most important document in a surgical chart. It is the official document that captures what transpired in the operating room. It must support the medical necessity for treating the patient, describe each part of the surgical procedure(s), and reveal the results of the surgery. The operative report is the document used most to reimburse claims for the surgeon, surgical team, and the facility. Auditors and payers use the operative report to verify that the documentation supports all codes reported on the claim. Let’s breakdown the four basic sections of an operative report and their requirements.

What’s in an Op Report?

The operative report consists of:

• Heading
• History/Indications for Surgery
• Body
• Findings and Follow-Up

The Heading of an operative report contains:

• Facility Information – Name and address of the facility and the patient’s medical record number for that facility.
• Patient Information – Patient’s full legal name, date of birth/age, and sex. Some procedures are sex-/age-specific.
• Date of Service – Date the surgery was performed.
• Surgery Information – Name of the primary surgeon, co-surgeons, residents, and/or surgical assistants; type of anesthesia; name of anesthesiologist/CRNA; use of special equipment (microscope, robotics, etc.) and/or implants; complications; and estimated blood loss.
• Pre-operative and Post-operative Diagnoses – List of all applicable diagnoses to support medical necessity.
• Procedure(s) Performed – A comprehensive list of the surgery or surgeries.

The History/Indications for Surgery section of the op report describes why the surgery is needed and the actions preceding the surgery, if applicable. The surgeon explains how the illness or injury occurred, the occurrence date or duration, the patient’s past medical history pertinent to the procedure, the patient’s family history pertinent to the procedure, past or failed treatments, etc.
The Body of the operative report contains:

Description of the Procedure(s) – All procedures from the beginning (prepping) to the end (closure and dressings) MUST be documented in this section. If the procedure was performed bilaterally, then both sides must be documented here in some fashion, even if it is already stated as such in the Heading. If performed unilaterally, the correct side must be documented.

The following should be documented as well: the approach (whether open or endoscopic); implantation of the implants or devices previously listed in the Heading; use of robotic or microscopic assistance previously listed in the Heading; any specimens collected or frozen sections performed; intraoperative monitoring or testing; and any portions performed by another surgeon.

Description of the Procedure(s) is the most important part of the operative report. This is where the basic principle of a coder’s mantra “NOT DOCUMENTED, NOT DONE” applies. If a procedure is not documented here, auditors/payers will either not reimburse for the missing procedure or recoup a previous payment for the missing procedure.

It is vital to code from this section and not code just from the procedure listings in the Heading. The procedures listed in the Heading should only give the coder a checklist of what to look for in the body of the operative report. If the coder finds a procedure is omitted, missing bilateral documentation, or any other discrepancies between the heading and the body, the surgeon should be queried immediately for verification and possible correction.

The Findings and Follow-Up should contain:

• Summary of Findings – Summarize the findings of the surgery.
• Complications – Any complications or absence of complications should be documented here.
• Follow-Up Treatment or Future Procedures – The surgeon should document any future (staged) procedures for proper modifier assignment. Follow up or repeat screening indications should be documented here as well.

Other Considerations

In certain instances, more definitive, reportable diagnoses or complications may be found in the History/Indications for Surgery section and Body of the operative report than what may be listed the Heading. In the case of co-surgeons, each surgeon should provide an operative report for their portion of the surgery. And for discontinued procedures, the reason for discontinuing the procedure must be documented.
A coder’s job is to read the entire report from start to finish to capture all billable services and be the first line of defense against any errors or discrepancies before the claim is submitted.

About the Author:
Jessica G. Kibbe, COC, CPC, CASCC, is an ASC coding specialist with Acadiana Coding Services. She has 19 years’ experience specializing in ASC coding and billing for multiple specialties. She also provides auditing, consulting, and on-site education services for ASCs and surgeons. She is the 2020 president-elect for the Lafayette, La., local chapter.

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