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op note

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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
- Jul 31, 2023
- gynecological op note
- Replies: 1
- Forum: OB/GYN
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...
- alexander
- Thread
- Jun 22, 2009
- ambulatory surgery op note surgery
- Replies: 0
- Forum: Outpatient Facilities

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