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Thread: Coding from surgical report

  1. #1

    Question Coding from surgical report

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    Good evening All: The help I recd regarding Anesthesia coding really helped refresh my memory, especially since I never had the opportunity to use it. I need help with something else now. Does anyone know the list of key terms that's used to assist in finding what the procedure being performed is? I haven't coded from surgeries in quite a while, and need some assistance. Thanks!

  2. #2

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    Components of an operative report:

    [LIST][*]Preoperative diagnosis - tentative diagnosis before surgery[*]Postoperative diagnosis - diagnosis after the surgery has been performed[*]Surgical procedure - concise statement of the procedure(s) performed[*]Indications for procedure - facts leading up to the decision for the surgery[*]Details of procedure - narrative detailed description of the surgical procedures[*]Signature of surgeon

    Common Procedural Terms of Method or Technique:

    • Incision
    • Excision
    • Destruction
    • Amputation
    • Introduction
    • Endoscopy
    • Repair
    • Suturing
    • Manipulation


    Also pay attention to the approach for example: Did the surgeon access surgical site throught the umbilical or the thoracic?


    Sample of questions to ask yourself to help determine a code (for example, removal of a lesion):

    • Was the lesion benign or malignant?
    • What technique was used to remove the lesion (laser, excision, or shaving)?
    • Where was the lesion?
    • Were there any additional procedures performed, such as intermediate wound closure?
    • What was the excised diameter (greatest clinical diameter) of the lesion?



    I could go on and on but I would probably be typing for hours. Pay strict attention to the guidelines for sequencing and modifiers.
    Last edited by TonyaMichelle; 12-08-2011 at 07:06 AM.

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