Results 1 to 3 of 3

Operative Report Audit

  1. #1
    Casa Grande & Phoenix
    Default Operative Report Audit
    Medical Coding Books
    Is there a specific auditing form for procedures/op reports? I have a very helpful E/M audit form but nothing for op reports. Any help is appreciated!!
    Tara Johnson, CPC

  2. #2
    Swainsboro/Statesboro, GA
    Default Procedure note auditing form
    I've never seen anything like this, but it's possible to develope your own auditing tools. I did this for E&M auditing, but I have also done this for other auditing projects. I find that I work better when I read the regulations on the subject I am auditing, and develope my audit tool from those CMS regulations.

    In your question of auditing procedure notes, it could be difficult to create individual procedure audit sheets, but if you are auditing some of the same procedures, it may be worth it to take the time to do so.

    You could also develope a "master" audit tool for all procedures (things that would be required no matter what the procedure), such as patient name, pre and post op diagnosis, physician name, procedure name, date, justification for the procedure, complications, outcome, physician signature, etc. Your employer may also have certain requirements that must be met, such as physician signature within a certain time frame.

    There are also some requirements in the Codes of Participation. These are usually included in your hospital policies, but it is always a good idea to verify this.

    Good luck!
    Freda Brinson, CPC, COC, CEMC
    AAPC Swainsboro/Statesboro Chapter
    2017/2018 Secretary/Treasurer
    2016 Education Officer
    2014/2015 President
    Past President - 2012, 2008; Past Vice President - 2013, Past Education Officer - 2009 of Savannah, GA Chapter
    Past Member AAPCCA Board of Directors (2009-2012)

  3. #3
    Casa Grande & Phoenix
    Default Op Report Audit
    Thanks so much for your help!!
    Tara Johnson, CPC

Similar Threads

  1. Help with operative report
    By maine4me in forum General Surgery
    Replies: 4
    Last Post: 02-09-2015, 05:50 AM
  2. Operative report help....Please!!
    By maine4me in forum General Surgery
    Replies: 0
    Last Post: 10-31-2013, 01:08 PM
  3. Operative Report?
    By veloso in forum Podiatry
    Replies: 1
    Last Post: 05-29-2012, 10:27 AM
  4. Help with operative report
    By codedog in forum Plastic Surgery
    Replies: 0
    Last Post: 05-24-2010, 11:23 AM
  5. operative report/path report
    By codedog in forum Outpatient Facilities
    Replies: 4
    Last Post: 04-09-2010, 07:47 AM

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.