Diagnosis in operative report

SUEV

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Local Chapter Officer
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When coding operative reports, is it required that the diagnosis be in the op note? For example, a provider states a colonoscopy is high risk on the op note but doesn't list the reason. Only when looking at the H&P do you find that the patient has a personal history of colon polyps. When billing for the provider, can we add the V12.72 even if it's not in the op note itself?
Thanks,
Sue
 

dpeoples

True Blue
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When coding operative reports, is it required that the diagnosis be in the op note? For example, a provider states a colonoscopy is high risk on the op note but doesn't list the reason. Only when looking at the H&P do you find that the patient has a personal history of colon polyps. When billing for the provider, can we add the V12.72 even if it's not in the op note itself?
Thanks,
Sue
My understanding of the issue is that any ICD code (9 or 10) assigned should be supported in the patient's medical record. In the imaginative perfect world, that code is clearly reflected in the document being coded. If you must obtain additional information from another source, so be it. Just know that any additional information used in assigning a code, should be easily accessable by potential auditors.

HTH :)
 

SUEV

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Local Chapter Officer
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Thanks for the response, Danny. I think I really want to live in that imaginative perfect world. It sounds nice there!
 
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