Op report coding

Anna Weaver

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Okay, here's for today. I am looking for the documentation to support the fact that you should not code from the Op report heading (i.e. procedure performed), rather use it as a confirmation of what is in the body of the report. I cannot find this, but know I have read it somewhere. Can anyone help?
 

junebug1969

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I don't have a source to point you to, but I would not code straight from the OP report heading either. Oftentimes I have found that I need to confirm certain details that affect code assignments that are only found in the actual report. (i.e. approach, accompanying conditions *such as bypass procedures*, etc.) Personally, I think coding directly from the heading is somewhat lazy coding. Although I'm sure it's faster, and you will get the correct answer sometimes (or even a lot of the time), I just think it's a bad policy for professional coders. That's just my two cents... :)
 

Anna Weaver

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OP report coding

Junebug, I agree wholeheartedly, The Dr's however think it's okay because they've already listed the procedure in there once. I too have had procedures listed in the heading that were not exact to what was in the body or not in the body at all. We're trying to find the documentation guidelines for this to show the Doc's so they will know we're not just saying this to make their life miserable.
 
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