Operative report documentation requirements


Best answers
Can anyone please direct me to where I can find the legal requirements to documentation of an operative report detailing the format and areas pertinent to abstracting your coding from?

Example of what I need would be: the CPT is derived from which section of the operative report? What is the title to that section? What is required in this section?
If the operative note lists the procedure performed but has no section titled "description of procedure" is it still acceptable to code from the procedure performed line?

Please note: the section titled Findings does not contain everything listed in the section titled Procedure Performed. What format and information is required in an operative report to support the CPT codes chosen?

Example operative note:

Preoperative Diagnosis: Microhematuria, urinary retention, and benign prostatic hypertrophy.

Postoperative Diagnosis: Microhematuria, urinary retention, and benign prostatic hypertrophy.

Procedure Performed: Cystoscopy, bilateral ureteral catheterization, bilateral retrograde pyelogram, cup biopsy of the bladder, fulguration of the prostate, placement of 20-French Foley catheter.

Anesthesia: MAC.

Indications: The patient with persistent urinary retention, prior microhematuria and UTIs.

Findings: Normal penile urethra, 2.5 cm prostate fossa with elevated bladder neck. It is not a tight high bladder neck. There was some anatomic opening. There was minimal lateral lobe tissue. The ureteral orifices had clear efflux bilaterally. There was prompt filling and drainage of collecting system bilaterally with no evidence of mass effect, filling defect, or point of obstruction or J looking. The bladder had grade 3 trabeculations with occasional cellules. There was also catheter reaction and the erythematous red patches throughout, which were irregular. We did a biopsy of this with specimen sent to Pathology. This area was then cauterized for hemostatic purposes and then there was bleeding at the bladder neck in the prostate fossa, which was cauterized as well with Bugbee cauterization. The bladder was filled and emptied and found to be intact. So then it was refilled and a 20-French Foley catheter was placed to gravity drainage. The patient was taken to recovery room awake, alert, and in stable condition. All counts were correct. No complication. No blood transfusion.

Doctors signature Date Time

Thank you!