Wiki Coding an Op note

[bjrepar]

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

 

[hopepg]

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.