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Thread: Pre-op Diagnosis

  1. #1

    Default Pre-op Diagnosis

    AAPC: Back to School
    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.

  2. #2
    Join Date
    Apr 2007


    I don't have any documentation but I work for an ASC and our doc's always dictate the Pre-op DX. If necessary to have it in the case there is no findings nor biopsies involved after the procedure is done...hope this helps!

  3. #3
    Join Date
    Apr 2007
    Kokomo, IN

    Default pre op diagnosis

    All our Doc's put the pre-op and post op diagnosis in their dictation. But, I can't find anything where it says it must be in there. The documentation I found (and lost again) says that it must be on the chart. But doesn't say it has to be in the OP report. I will look for that documentation again.

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