Documentation Guidelines for Same Day Surgery


Reno, NV
Best answers
Good Morning,

I audited an account and the coder coded a surgery that had no OP report. When I sent an e-mail to the Coding Supervisor, the responded with the following, "
As per instruction received we need to complete all such aging accounts DNFB > 30 Days to avoid timely filing limit irrespective of missing operative report/charges. " I know we cannot code without an OP report, but I need a reference to cite when responding to this e-mail. I have searched CMS and I have found information before but have never encountered this, to add to a favorites....

Any help is appreciated!


True Blue
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The fact that all codes must be supported by documentation is such a basic tenet of correct coding, that you do not need to provide a reference for this, although I'm sure you could find many. There is no way to code a surgery without an operative report. I would simply cite this an error for a code not supported by documentation. The fact that an instruction was given to the coder to submit the codes within 30 days 'irrespective' of missing documentation does not make the coding correct. As an auditor, I would absolutely reject this rebuttal - it is not a valid reason or excuse.