# surgical note v's operative report



## codedog (Mar 26, 2009)

Can someone help me with this situation;

 I have some doctors that do not dictate on  the same day as the sugery-they may dictate that sugery  weeks after the sugery. in some cases months.From a legal point, can they just have a sugical note saying what proceure was done with a dx,then can I code it. My supervisor says we need to hurry and bill, but I say  we are losing out because even though he wrote the procedure down, example -excision of mass- we may be losing because it doe not say  how he sutures it.Is there a web site that says the guidelines,  trent -please help


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## RebeccaWoodward* (Mar 26, 2009)

*Documentation. *

*Timely*, accurate and complete documentation is important to clinical patient care. This same documentation serves as a second function when a bill is submitted for payment, namely, as verification that the bill is accurate as submitted. Therefore, one of the most important physician practice compliance issues is the appropriate documentation of diagnosis and treatment. Physician documentation is necessary to determine the appropriate medical treatment for the patient and is the basis for coding and billing determinations. Thorough and accurate documentation also helps to ensure accurate recording and timely transmission of information.

 Medical Record Documentation.

In addition to facilitating high quality patient care, a properly documented medical record verifies and documents precisely what services were actually provided. The medical record may be used to validate: (a) The site of the service; (b) the appropriateness of the services provided; (c) the accuracy of the billing; and (d) the identity of the care giver (service provider).

http://www.oig.hhs.gov/authorities/docs/physician.pdf

Although this does not give a "time frame", weeks and months are unacceptable.  Our hospital provides a "deliquency" list.  This list provides the names of those patient's whose dictation is pending for completion.  There are consequences for repeat offenders.  I, personally, know of a practice who, unexpectedly, lost a surgeon.  Some of his operative notes where not dictated due to his untimely death.  Needless to say, it did pose a problem for some of those claims.

Also...I never post surgical charges until I have the op note in hand.  Many, many times, the surgeons leave off payable cpt codes or the assistants fees. It is imperative that you have the op note in front of you for correct coding.


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## codedog (Mar 26, 2009)

Thank you for the info Rebecca. Trent


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## FTessaBartels (Mar 26, 2009)

*Rebecca is absolutely right*

Very well stated, Rebecca!

F Tessa Bartels, CPC, CEMC


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