Go Back   AAPC Forum > Medical Coding > Medicare Regulations
Forum Rules FAQ Members List Calendar Search Today's Posts Mark Forums Read

Thread Tools
Old 02-20-2009, 11:46 AM
jtb57chevy jtb57chevy is offline
Join Date: Apr 2007
Posts: 63
jtb57chevy is on a distinguished road
Question Pre-op diagnosis

Is a pre-op diagnosis required on an operative note? In the past the surgeons I worked with always included the pre-op diagnosis in their notes. I now work for a physician who does not dictate a diagnosis on procedure notes. Before I discuss this with him, I'd like to have documentation for backup. I've searched CMS & can't find any guidelines. I found a guideline on JCAHO, but it doesn't indicate that a pre-op diagnosis is required, just a post-op diagnosis.

Thanks for any thoughts
Reply With Quote
Old 02-23-2009, 11:32 AM
mrsclark75 mrsclark75 is offline
Join Date: Apr 2007
Posts: 10
mrsclark75 is on a distinguished road
Default pre-op diagnosis code

I am currently taking a coding course and there is a chapter on Operative notes, and it states in my text book that the operative report should contain.. "Medical neccessity of the procedure for the treatment of the patient's condition (preoperative diagnosis)". preoperative diagnosis should be listed on the Operative report to support medical necessity.

I hope this helps,
Reply With Quote
Old 02-24-2009, 07:32 AM
fredabrinson fredabrinson is offline
True Blue
Join Date: Apr 2007
Location: Swainsboro/Statesboro, GA
Posts: 752
fredabrinson is on a distinguished road
Default Regulations

You may also want to check with the Medical Staff or Medical Records Departments of the hospital where your physician is providing these services. Hospitals have Federal Conditions of Participation that must be followed and what needs to be contained in an operative note is included in that document.

Here is the website for the COP (Conditions of Participation):


And here is the main page:


Hope this helps!
Savannah, GA
Reply With Quote

Thread Tools

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off

Disclaimer: Although AAPC staff members will monitor these forums periodically, we cannot be responsible for the information posted herein, nor guarantee its accuracy. Our members may discuss various subjects related to medical coding, but none of the information should replace the independent judgment of a physician for any given health issue. Please note that the opinions expressed here do not necessarily reflect those of AAPC.

All times are GMT -6. The time now is 06:23 AM.

Powered by vBulletin® Version 3.8.1
Copyright ©2000 - 2015, Jelsoft Enterprises Ltd.
Copyright ?2015, AAPC