In Billing
Apr 26th, 2016
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 ...
In Coding
Jun 15th, 2015
by John Verhovshek, MA, CPC A surgeon’s operative notes should stand alone to provide all the necessary documentation to describe the procedure(s) performed. Every operative note should include: Patient’s name Date Preoperative Diagnosis Postoperative Diagnosis Surgeon’s Name Assistant Surgeon/Co‐Surgeon Procedure Indications for Surgery Findings at Surgery Details When possible, differentiate pre-...
Oct 1st, 2012
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 ...