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OP Report Question

  1. Default OP Report Question
    Medical Coding Books
    Do many of you have the H&P available when you code the surgery, or just the report? For those of you that have the H&P available, if the diagnosis there is more specific do you use that or what the provider stated in the OP report?

    Thanks for your input.

  2. #2
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    NEW ORLEANS
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    I always go by the operative report.

  3. #3
    Location
    Columbia, MO
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    I almost never have the H&P with an op note so I always go by what is in the op note also.

  4. #4
    Location
    ENGLEWOOD/DENVER
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    I also always go by the op report. The H & P is done prior to surgery therefore may not be as accurate as the op report which "should" reflect the findings in surgery.

    Mary, CPC, COSC

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