As long as the procedure is adequately documented, yes, you may code from a handwritten procedure note. "Adequately documented" will include legibility of the note, date of service, clear indication for procedure, clear description of what was done (not just a title), clear indication of who is performing the procedure and the provider's signature and date.
I have coded a procedure (e.g. laceration repair) when it is only handwritten and not dictated/transcribed.
BUT ... most hospitals require a dictated operative note for anything requiring anesthesia and/or not done at bedside.
Hope that helps.
F Tessa Bartels, CPC, CEMC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join