'Findings' Section in Your Op Report Can Make Biling Easier
Published on Wed Mar 01, 2000
Otolaryngologists should include a short section in their op notes that explains what they found, what they did and why they did it, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of the CPTs executive committee. Although physicians have very good reasons for performing the procedures they do, that information may not be as obvious to others, Eisenberg says, noting that office staff, carriers, and other doctors all benefit if the op note contains such a Findings section.
Physicians make a lot of intuitive decisions that others may not follow. A Findings section would help othersyour own staff, reviewers at the carrier, and even other physiciansunderstand your thinking and the procedure quickly, he says. The detailed information usually reported in the body of operative reports is not as important as what the otolaryngologist found.
There is too much extraneous material in the body of the op note, Eisenberg says. Nobody cares what suture you used to tie off a blood vessel. Whats important is why you tied off the blood vessel.
Such a section does not need to be long. One or two paragraphs usually are enough to describe the findings that implicitly match what the otolaryngologist performed surgically, Eisenberg says.
Pathology Provides Important Information
The Findings section should describe what the pathology was at the time of surgery. If thats done appropriately, it will explain why the procedures performed were chosen, he says.
For example, when an otolaryngologist inserts tympanostomy tubes (6943x, tympanostomy requiring insertion of ventilating tube), the findings section might say: Findings: There was thick fluid in both middle ears. The right tympanic membrane was adherent to the promontory. For these reasons t tubes were placed.
This short paragraph explains what the otolaryngologist found (thick fluid in both middle ears, right tympanic membrane adherent to the promontory). It notes what the otolaryngologist did to correct the problem (the placement of tubes) and, by adding three wordsfor these reasonssuccinctly explains why the tubes were placed.
In another example, an otolaryngologist performed a tympanoplasty with mastoidectomy without ossicular chain reconstruction (69635, tympanoplasty with antrotomy or mastoidotomy [including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair]; without ossicular chain reconstruction). A good findings section might read: There was a total central perforation. In the mastoid a cholesteatoma was found extending into the middle ear and involving the incus and stapes including the footplate. The facial nerve was covered. The IS joint was eroded. The footplate was mobile. The chorda tympani was involved with the cholesteatoma and had to be sacrificed. (This explains why the chorda tympani was removedbecause removing the chorda tympani changes taste sensations, there needs to be a good reason for doing it.) [...]
