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Coding without op notes or path reports?

  1. #1
    Default Coding without op notes or path reports?
    Medical Coding Books
    I was recently told by one of the physicians I work for, that I was to code surgeries on the day they are done, without waiting for either the op note and/or path report. I was told that if I had questions about the procedure performed or diagnosis, I was to ask the surgeon. I was also told that " are smart, and should have known to code procedures immediately...". In addition, " you really need an op note for ear tubes and T&A's...?" Coding without op notes and/or path reports goes against everything I learned in my coding class. I'd appreciate feedback.


    Molly O'Connor, CPC

  2. #2
    Seacoast- Dover New Hampshire
    I always wait for path report where a biopsy has been done. this is correct coding.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. #3
    Columbia, MO
    While you can code with out the path report (except of skin lesion excisions), you cannot code without the op note. You cannot make an assumption of what was performed and you cannot just take the providers procedure listing as the description of the procedure. Many times what the provider says he did does not 100% match the procedure description. You can code the findings without the path report if the path report is unavailable at the time of coding. (again except for skin lesion excisions where you must wait for the path report.)

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Coding without the op note and therefore without knowing what was done is the craziest thing I have ever heard of. Sounds like an easy way to get charged with fraud.

  5. #5
    Jacksonville Florida Chapter
    That makes no sense!

    I externed for a practice that coded office visits without the chart notes because they had their codes on their fee tickets meaning their providers did all the actual coding. If something was wrong, it was up to their billers (most of whom were not coders) to try to fix things. That meant that their billers would have to get with their coders (who were all in different locations) to get their claims fixed to re-submit.

    Coding operations without op notes is just stupid since we all know that coding operations is usually harder than coding office visits.

    I agree with Colorectal Surgeon.... It sounds like a good way to have a visit from the IG for fraud investigations.
    John Meyer, CPC
    Heekin Clinic

  6. Default
    I agree that you absolutely have to wait for the OR report. Regardless of what procedure is booked, it depends on the documentation what you will bill. What if the procedure is done but is stopped due to complications? Or what if a simple procedure is booked and more ends up being done? One of the main rules in coding is not documented, not done, so I would tell the provider, you cant bill until you have the documentation to back up.

  7. #7
    Another issue you could run into if you do not have a report is what if the doctor forgets to dictate the note or he dictates it and it is never transcribed? You would not have anything to support your charge if you were ever audited.
    Susie Corrado, CPC
    ENT Coding/Billing

  8. Default
    Remember its your certification, and if you are audited, they will come back on YOU. I would wait until you get the OP note and Path Report. Kathy Albert,CPC

  9. #9
    Everett, WA
    Glad i found this thread since answers to my "blind billing" question were sparse. So, it appears to be a common issue and glad I'm not the only once concerned about all of this. whether it be CODING or BILLING or BOTH.
    ---Suzanne E. Byrum CPC

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