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required documentation?

  1. #1
    Default required documentation?
    Medical Coding Books
    Can anyone direct me towards something that states what is required documentation for an operative report.

    I have a doc who give me "op report" that is one sentence long stating " I & D was done great toe right foot". I gave it back to him and told him it was not an op report........I told him you need pre-op dx, post-op dx, proced performed, anesthesia used, ect.....

    So now he wants to "see" something stating requirements for a "report"


  2. #2
    I like this article:

    Ask said doc if his "one-liner" would have passed muster by his teaching physician when he was a resident.

  3. #3
    Hello All,
    I would like to know what is requirement for coding out -pt clinics.
    Is super - bill alone would be enough to code - or coders need to review progress note.



  4. #4
    Default Op Report Documentation
    Have you tried searching CMS website for an online manual? I did attend a conference on coding from the op report several years ago, and I know that the procedure name, pre- and post-op diagnosis, and a detailed description of the surgery itself is required. The description needs to include the method of of surgery, ie open vs laparascopic, incisions made, closure, any complications or justification for a -22 modifier. It also needs to include the disposition of the patient, ie awakened from anesthesia and taken to recovery. It should also include any findings to support the diagnosis. Hope this helps some.


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