Coding from surgical report

[REGINALD068]

Good evening All: The help I recd regarding Anesthesia coding really helped refresh my memory, especially since I never had the opportunity to use it. I need help with something else now. Does anyone know the list of key terms that's used to assist in finding what the procedure being performed is? I haven't coded from surgeries in quite a while, and need some assistance. Thanks!

 

[TonyaMichelle]

Components of an operative report:

• Preoperative diagnosis - tentative diagnosis before surgery
• Postoperative diagnosis - diagnosis after the surgery has been performed
• Surgical procedure - concise statement of the procedure(s) performed
• Indications for procedure - facts leading up to the decision for the surgery
• Details of procedure - narrative detailed description of the surgical procedures
• Signature of surgeon
  
  Common Procedural Terms of Method or Technique:
  
  • Incision
  • Excision
  • Destruction
  • Amputation
  • Introduction
  • Endoscopy
  • Repair
  • Suturing
  • Manipulation
  
  Also pay attention to the approach for example: Did the surgeon access surgical site throught the umbilical or the thoracic?
  
  
  Sample of questions to ask yourself to help determine a code (for example, removal of a lesion):
  
  • Was the lesion benign or malignant?
  • What technique was used to remove the lesion (laser, excision, or shaving)?
  • Where was the lesion?
  • Were there any additional procedures performed, such as intermediate wound closure?
  • What was the excised diameter (greatest clinical diameter) of the lesion?
  
  
  I could go on and on but I would probably be typing for hours. Pay strict attention to the guidelines for sequencing and modifiers.