Surgery Documentation Guidelines

lcterry

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I am in need of documentation from Medicare, or the STS, or the AMA, or a comparable society, surgery documentation guidelines for my physicians.

I have been at my new job for 6 months, and the physicians have "always documented this way", they are wanting me to code from the procedure header and not the body of the description of the procedure.

I had a recent report that was documented this way:

"Procedure: right thoracotomy: upper lobectomy, medistinal lymphadenecotomy

Description of procedure: A mass was found in the upper lobe of the right lung. The patient tolerated the procedure well, and was taken to the recovery room in stable condition."

The physician in charge of the other the other physicians told me there was nothing wrong with this report, and that I should code from the Procedure header. I told him I would not do that, and now I'm to get surgery documentation guidelines from a reputable society to back up what I am saying.

Any help anyone could give me would be appreciated.
 

trose45116

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i would never code from the procedure heading. i always code from the body of the report. the heading and the body may not be the same you can say one thing and not document it in the body. sounds like they need training on how to document.
 

kielee

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Help...

I am in need of documentation from Medicare, or the STS, or the AMA, or a comparable society, surgery documentation guidelines for my physicians.:D


I am in need of something more recent...I tried the link for joint commission..But it is not there anymore...Anyone know where I can get this info??? Please...and Thank you!
 
Last edited:

tlivengo

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I also need this information... something stating the rules on documenting procedures in both the Heading of the Surgery AND the body of the Report.

Some of my providers only put things in the Header and think that's enough.

Anyone??
 

ICD10CM/PCS

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the link below is to the joint commisions standards for an op report. It gives a very nice description of what they feel should at least be in an op report.

http://www.jointcommission.org/accreditationprograms/office-basedsurgery/standards/faqs/management+of+info/patient+specific+info/operative_reports.htm


hi

i coudn't get the operative notes guidelines or report from the web link which you had given. Im planning to take the cpma exam. Im looking for surgery documentation guidelines.
 
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