TnRushFan
Networker
Hello everyone,
My Chief of Surgery and I have a difference of opinion.
He thinks the surgery coders should review the entire medical record to glean information for coding the surgery encounter. I think the operative note should be a 'stand alone' document with all the information pertaining to that surgical encounter included in it.
I have researched the internet but have found nothing conclusive to support either rationale. Does anyone have a reference to support either, if I am incorrect I will glad to know that and let him know he was in fact correct.
Thank you in advance for any thoughts/input.
My Chief of Surgery and I have a difference of opinion.
He thinks the surgery coders should review the entire medical record to glean information for coding the surgery encounter. I think the operative note should be a 'stand alone' document with all the information pertaining to that surgical encounter included in it.
I have researched the internet but have found nothing conclusive to support either rationale. Does anyone have a reference to support either, if I am incorrect I will glad to know that and let him know he was in fact correct.
Thank you in advance for any thoughts/input.