Wiki Pre-op diagnosis

[jtb57chevy]

Is a pre-op diagnosis required on an operative note? In the past the surgeons I worked with always included the pre-op diagnosis in their notes. I now work for a physician who does not dictate a diagnosis on procedure notes. Before I discuss this with him, I'd like to have documentation for backup. I've searched CMS & can't find any guidelines. I found a guideline on JCAHO, but it doesn't indicate that a pre-op diagnosis is required, just a post-op diagnosis.

Thanks for any thoughts

 

[mrsclark75]

pre-op diagnosis code

I am currently taking a coding course and there is a chapter on Operative notes, and it states in my text book that the operative report should contain.. "Medical neccessity of the procedure for the treatment of the patient's condition (preoperative diagnosis)". preoperative diagnosis should be listed on the Operative report to support medical necessity.

I hope this helps,

 

[fredabrinson]

Regulations

You may also want to check with the Medical Staff or Medical Records Departments of the hospital where your physician is providing these services. Hospitals have Federal Conditions of Participation that must be followed and what needs to be contained in an operative note is included in that document.

Here is the website for the COP (Conditions of Participation):

http://www.access.gpo.gov/nara/cfr/waisidx_07/42cfr482_07.html

And here is the main page:

http://www.gpoaccess.gov/cfr/index.html

Hope this helps!
Freda
Savannah, GA