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op note

  1. B

    Wiki OP NOTE CPT CODING

    We have one physician who never states in the description of the OP note that he is removing ovaries/tubes with the uterus. However, he does state it like this: PROCEDURE PERFORMED: Robotic-assisted laparoscopic supracervical hysterectomy with bilateral salpingo-oophorectomy PATHOLOGY...
    • bag4498
    • Thread
    • gynecological op note
    • Replies: 1
    • Forum: OB/GYN
  2. A

    Wiki Op note

    Is the op note the only place that you can pull the "reason for the surgery" from, or if you need a more specific DX can you pull the "reason for surgery" from the H &P? example=op note states glaucoma, H&P states POAG. If there is a guideline stating that you can go to the H&P-please reference...
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