The entire operative note should be reviewed prior to assigning codes
Review the provider?s entire operative note to make sure that billable services are not missed. Incorrect code choices may result if you code only from the documentation headers. As an example, the operative report header report may list the procedure the provider expected to preform, but the body of the note may record a more extensive or entirely different procedure due to circumstances unforeseen. In addition, the body of the note could contain important diagnostic information or other content for billing purposes.
In case of Diagnosis code, reporting the post-operative diagnosis code must be used for coding unless there are further defined diagnoses or additional diagnoses found in the body of the operative report. If a pathology report is available, the findings from the pathology report must be used for the diagnosis.
- Start to make a note of the procedures listed.
- Read the note in its entirety to verify the procedures listed in the header. Procedures in the header may not be listed correctly, and procedures documented within the body of the report may not be listed in the header.
- All procedures reported should be documented within the body of the report.The body may indicate a procedure was abandoned or complicated which may indicate a need for a different procedure code, or to append a modifier.
- Looking for key words?Key words may include such as:
- Locations and anatomical structures involved,
- Surgical approach,
- Procedure method (Debridement, drainage, incision, repair, etc.),
- Procedure type (open, closed, simple, intermediate, etc.),
- Size and number, and
- The surgical instruments used during the procedure.
- Highlight unfamiliar words?Research for understanding.