Results 1 to 3 of 3

documentation of surgeries

  1. Default documentation of surgeries
    Medical Coding Books
    I have a doctor in my facility that is questioning if this is legal. Does an operative report have to be a written document in the patients chart OR can the op note be an audio on a cd and kept inside the chart? Does anyone know where I might look to find something documented on this so that we may show him if this is or is not acceptable? Any help would be greatly appreciated.

  2. #2
    Milwaukee WI
    Default How would he transmit to other providers?
    If it's only on an audio CD how would he share this info with other providers, insurance company, even the patient him/herself? Also how can the surgeon "sign" his work if it's audio. Who is to say whether that is the surgeon dictating?

    Also most facilities require an operative report in the chart within 24-48 hours.

    I'd check with CMS for more guidance. It just makes sense that the document should be in a written format (typed or handwritten).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    North Carolina
    Both residents and teaching physicians may document physician services in the patient's medical record. The documentation must be dated and contain a legible signature or identity and may be: ■ Dictated and transcribed; ■ Typed; ■ Hand-written; or ■ Computer-generated.

    I'm still looking for any other CMS citations

Similar Threads

  1. 2 surgeries
    By Kim M Gordon in forum General Surgery
    Replies: 0
    Last Post: 04-10-2012, 08:47 AM
  2. surgeries
    By parker777 in forum Medical Coding General Discussion
    Replies: 5
    Last Post: 12-02-2011, 03:05 PM
  3. 2 surgeries
    By beretchris in forum Billing/Reimbursement
    Replies: 0
    Last Post: 06-17-2010, 11:30 AM
  4. Help with Surgeries
    By broundy in forum General Surgery
    Replies: 0
    Last Post: 05-11-2010, 01:05 PM
  5. Eye surgeries
    By KNP40806 in forum Outpatient Facilities
    Replies: 2
    Last Post: 10-07-2008, 03:25 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.