AAPC - Back to school
Results 1 to 4 of 4

Thread: surgical note v's operative report

  1. #1
    Join Date
    Apr 2007

    Default surgical note v's operative report

    AAPC: Back to School
    Can someone help me with this situation;

    I have some doctors that do not dictate on the same day as the sugery-they may dictate that sugery weeks after the sugery. in some cases months.From a legal point, can they just have a sugical note saying what proceure was done with a dx,then can I code it. My supervisor says we need to hurry and bill, but I say we are losing out because even though he wrote the procedure down, example -excision of mass- we may be losing because it doe not say how he sutures it.Is there a web site that says the guidelines, trent -please help

  2. #2
    Join Date
    Apr 2007
    North Carolina



    Timely, accurate and complete documentation is important to clinical patient care. This same documentation serves as a second function when a bill is submitted for payment, namely, as verification that the bill is accurate as submitted. Therefore, one of the most important physician practice compliance issues is the appropriate documentation of diagnosis and treatment. Physician documentation is necessary to determine the appropriate medical treatment for the patient and is the basis for coding and billing determinations. Thorough and accurate documentation also helps to ensure accurate recording and timely transmission of information.

    Medical Record Documentation.

    In addition to facilitating high quality patient care, a properly documented medical record verifies and documents precisely what services were actually provided. The medical record may be used to validate: (a) The site of the service; (b) the appropriateness of the services provided; (c) the accuracy of the billing; and (d) the identity of the care giver (service provider).


    Although this does not give a "time frame", weeks and months are unacceptable. Our hospital provides a "deliquency" list. This list provides the names of those patient's whose dictation is pending for completion. There are consequences for repeat offenders. I, personally, know of a practice who, unexpectedly, lost a surgeon. Some of his operative notes where not dictated due to his untimely death. Needless to say, it did pose a problem for some of those claims.

    Also...I never post surgical charges until I have the op note in hand. Many, many times, the surgeons leave off payable cpt codes or the assistants fees. It is imperative that you have the op note in front of you for correct coding.
    Last edited by RebeccaWoodward*; 03-26-2009 at 09:24 AM.

  3. #3
    Join Date
    Apr 2007


    Thank you for the info Rebecca. Trent

  4. #4
    Join Date
    Apr 2007
    Milwaukee WI

    Default Rebecca is absolutely right

    Very well stated, Rebecca!

    F Tessa Bartels, CPC, CEMC

Similar Threads

  1. Please Help-Ortho Operative Note
    By AR2728 in forum Orthopaedics
    Replies: 2
    Last Post: 07-13-2011, 08:45 AM
  2. operative report/path report
    By codedog in forum Outpatient Facilities
    Replies: 4
    Last Post: 04-09-2010, 07:47 AM
  3. PLEASE help w/ Ankle operative note
    By Lisa Heikes in forum Orthopaedics
    Replies: 0
    Last Post: 01-04-2010, 10:27 AM
  4. coding an operative note
    By mksmith713 in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 05-07-2009, 06:46 AM
  5. Operative note help..tricky one
    By 1073358 in forum Cardiology
    Replies: 0
    Last Post: 12-18-2008, 03:35 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.