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Thread: what is require on a op report

  1. #1

    Default what is require on a op report

    AAPC: Back to School
    the surgeons sometimes leave off "operation performed","post operative diagnosis" but put the information in the body of the report. Can we still code or do we ask the surgeon to amend.


  2. #2
    Join Date
    Apr 2007
    Seattle First Hill


    We always ask our surgeons to amend them.

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default The information IS there

    If I understand you correctly, kstark, the information is present, but just not under the correct section (subtitle).

    If the information is present ... regardless of where it is in the report ... I do NOT ask the surgeon to amend.

    If the information is missing, I ask the surgeon to amend.

    F Tessa Bartels, CPC, CEMC

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