I have operative notes that do not include any diagnosis (pre or post Op).
Being "old School" I suggested an addendum to the provider to update his note prior to billing. I was told that according to the AMA you can take the diagnosis from the H&P. That just doesn't ring true. I might be able to see it for an ASC charge as the facility is getting the H&P as part of chart paperwork but even that is a stretch for me.
I started coding before EMRs, and live by the rules of, not documented not done and stand alone documents, but to make sure I am looking for credible references to prove that a operative note must have a diagnosis listed. I would love to see anything that the AMA has on this topic, but I have not been able to get into the website.
Can anyone help me?
I have JCAHO Standard IM.6.30 so far.
Thank You
I agree in principle that the op note should have the diagnosis included. However, I must admit in practice that I very often refer to the intake documents (for chief complaint), H&P, and other medical records (imaging, etc) to gather a full picture of a case. When we get denials on such a case requesting medical records, we submit both the op note and any other documents we have to support the claim. I mean all of those documents are a part of the medical record, right? So long as they share the same date and provider as the surgical op note I have no compunction about using them to justify a claim.
There are so many EMRs out there now, I really can't speak in generalities about them. However, one specific EMR that I use (I do third party coding for anesthesiologists, I use multiple EMRs) organizes incidents (AKA encounters, visits, tickets) by date of admission, and has separate document upload spaces for H&P, operative reports, anesthesia records, imaging, etc. In other words it forces the physician to document in a certain way, which might cause problems if you are strictly following the "stand alone documents" idea you referenced. I often have to reference multiple documents to get a complete picture of an anesthesia case. The anesthesiologist isn't the primary surgeon, so his anesthesia record will often make only superficial reference to the diagnosis that justified the procedure (I am speaking now of the worse possible case - every case isn't like this!). This leads to a little digging around to find the primary surgeon's H&P or the operative report, or perhaps the pre-op anesthesia write up for the primary diagnosis. I consider a bit of research to be part of coding a case (whether its looking for a diagnosis or looking for a code for a diagnosis, it's all the same to me). If I can find an answer on my own by going through the medical records, there's no reason to send it back to the MD for him or her to do the same search.
Obviously this is an opinion (everything on these forums has to come with a disclaimer apparently). I don't doubt someone else will be along shortly (or, indeed, before me) with an opinion contrary to mine. If you want references though, I don't have any. It seems to me common sense that if a surgeon does an H&P and then later the same day does a surgical procedure that his H&P is apart of that same medical record. I started coding well after the rise of EMRs though, so I can't say I fully "get" the "stand alone document" idea.