what part of the operative report is used to assign a diagnosis code?

Op Note Documentation Tips Every Surgeon Can Use

May 1, 2019

Yous've submitted, in a timely manner, correct Current Procedural Terminology® (CPT) codes to the insurance company for the procedure you performed. The payor's explanation of benefits (EOB) or electronic remittance communication (ERA) shows a payment of $0! At present what? Typically, you'd send in the operative annotation, showing the clarification of the process you lot performed.

The operative notation is not only a dr.-legal and patient care document. Information technology'southward normally the simply information a payor wants when there is a dispute about your reimbursement.

So let's walk through some key elements of the operative report documentation.

Pre-operative and Post-operative Diagnoses

All relevant pre- and post-operative diagnoses should be documented, including underlying co-morbid conditions that y'all consider relevant for the process performed. If a pre-op diagnosis is no longer relevant, or changes intra-operatively, then state this in the post-operative diagnosis statement.

For instance, if the tumor or lesion pathology is not known pre-operatively, information technology is acceptable to state "unknown" in the pre-op diagnosis. If the frozen section comes back positive for a malignancy, this could be stated in the postal service-op diagnosis area.

Surgeon

The primary surgeon for the procedure is listed equally the surgeon. In the academic environment, this is the attending surgeon for the procedure.

Assistant Surgeon vs. Co-Surgeon vs. Assistant at Surgery

Not crystal clear on the difference? Here are some tips that describe the different surgical roles typically seen in a procedure.

Assistant Surgeon	Co-Surgeon	Assistant at Surgery
-Assists in the main procedure as a "skilled extra pair of easily." -Has no pre-op responsibility. -Does non dictate an operative notation. -Not primarily responsible for mail-op care. -Clinical necessity for the billable assistant surgeon and role during the procedure is documented in the operative note by primary surgeon. -Recall to certificate the teaching physician attestation statement when a faculty assistant surgeon is besides being billed. -Modifier 80 (Assistant Surgeon) or 82 (Banana Surgeon (when qualified resident surgeon non available) is used. –Example: Your partner General Surgeon assists y'all with a total thyroidectomy. You report 60240 for the total thyroidectomy and your partner reports 60240 with modifier eighty (60240-lxxx).	-Ever documents a dissever operative note for his/her portion of the procedure. -Has pre-op and mail service-op responsibility. -Brings different expertise to the table – Medicare and many payors require the co-surgeon to exist of a different specialty (east.chiliad., General Surgery and Neurosurgery). -Directs a portion of the primary procedure – meaning the aforementioned CPT lawmaking is reported by both the primary surgeon and the co-surgery appended with modifier 62 (Ii Surgeons). –Example: The General Surgeon places the distal catheter, via laparoscopic technique, for a ventriculo-peritoneal shunt while the Neurosurgeon places the proximal catheter and valve. Both surgeons study the VP shunt code, 62223 with modifier 62 (62223-62).	-Assists in the primary procedure equally a "skilled extra pair of hands." -Has no pre-op or post-op responsibility. -Does not dictate an operative annotation. -Clinical necessity for the billable assistant at surgery and role during the procedure is documented in the operative note past primary surgeon. -Modifier Every bit (Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery) is typically used, though some payors may require a different modifier. –Case: Your Physician Assistant assists you with repair of a strangulated inguinal hernia repair on an adult. The primary surgeon reports 49507 and the PA reports 49507 appended with modifier AS (49507-As).

Procedure(s) Performed

The procedures performed are listed in this surface area of the operative note, which is typically on the top half of the first page. We recommend using CPT terminology equally much as possible, but not including codes in the operative note. Why? Oftentimes, the codes documented in the operative annotation are not authentic.

It becomes a compliance upshot when the codes in the operative report do not match the codes billed on the CMS 1500 claim form. Medicare's Full general Principles of Medical Record Documentation state the CPT and ICD-10-CM codes reported on the health insurance claim grade or billing statement should exist supported by the documentation in the medical tape. When a CPT code is documented in the operative report simply not billed the CPT code billed is not "supported by the documentation in the medical record" as Medicare requires.

Indications for Surgery

This curt paragraph, a couple of sentences, is very important every bit it provides the clinical necessity for the procedure being performed. Information technology is as well important to land any previous, related surgery on the aforementioned or dissimilar structure/wound, why patient is being brought back to the OR, or planned future surgery, as these are clues that coders use to support specific modifiers.

For example, a patient may require stages, of surgery to reconstruct an open wound which would warrant use of modifier 58 (Staged or Related Process or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period). Stating clearly that the staged procedures are prospectively planned, in this case, would tell the coder and payor that modifier 58 is warranted and the total allowable should be paid. All too often, when the planned nature of multiple procedures is not documented, a modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Intendance Professional Following Initial Process for a Related Procedure During the Postoperative Period) is used, which generally results in a payment reduction.

Complexity

This separate paragraph is a must if modifier 22 (Increased Procedural Services) will be used to obtain additional payment. This data should summarize the added complication that volition exist in the subsequent details documented in the operative note.  Don't expect a payor to wade through the details of the operative annotation to attempt to figure out whether to pay you more. Go far easy for the payor to "feel your pain" of the procedure in a Complexity, or Findings at Surgery, paragraph.

Details or Clarification of Procedure

This is typically the lengthiest expanse of the operative note that describes the process(s) performed in cracking detail. Documentation should include, but not be limited to, consecration of anesthesia, patient positioning, fix-upwardly and use of special equipment (e.g., stereotactic navigation, robot), specific brand name of any implant(s), which surgeon did what when more than than i surgeon is involved, etc.

The details in this section of the operative notation should back up the procedures listed in the aforementioned Process(s) Performed area, which should as well support the CPT code(s) reported for the procedure(s).

Writer - Kim Pollock, RN, MBA, CPC, CMDP

Kim is a nationally recognized coding expert. Her energetic and engaging teaching style makes her a sought-after educator, trainer and speaker. Her nursing groundwork provides her with the ability to understand both the clinical and coding attributes of a procedure. She is an adept in analyzing chart documentation and in reengineering practices to enhance the reimbursement process. Click here for more than info about the author.

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Source: https://www.karenzupko.com/op-note-documentation-tips-every-surgeon-can-use/

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