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Wiki Coding an Op note

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bjrepar

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What can I use to code an operative note for professional side?
Can I use the encounter note with the decision to go to surgery along with the op note? Or do I only code from the op note? Do you have anything in writing on this?

Thank you for your help in this matter
BobbieJo
 
Procedures should be coded from the operative note where provider/physician details what was done during actual procedure. Diagnosis codes can be coded from operative note or maybe the clinic notes where provider/physician documents the reported condition(s) indicating surgery is recommended.
 
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