Most of my time is spent coding both inpatient and outpatient operative reports and cross walking to the appropriate anesthesia CPT for our CRNAs. I have a couple questions regarding documentation (not the CRNA's documentation, I am referring to the surgeon's operative report.) 1. Does the surgeon's report need to be complete, or can I code from the brief op note the surgeon dictates as long as it has a procedure and dx? 2. If a operative report shows gangrene, osteomyelitis, and/or ulcerations of the foot without mentioning the patient has diabetes, but diabetes is documented elsewhere on the patient's chart, can I include the diabetes in my coding, or does it have to be mentioned on the surgeon's operative report?
Any input would be appreciated.
Any input would be appreciated.