# Is the Operative Note a "stand alone" document



## TnRushFan (Aug 15, 2017)

Hello everyone,

My Chief of Surgery and I have a difference of opinion. 

He thinks the surgery coders should review the entire medical record to glean information for coding the surgery encounter. I think the operative note should be a 'stand alone' document with all the information pertaining to that surgical encounter included in it. 
I have researched the internet but have found nothing conclusive to support either rationale. Does anyone have a reference to support either, if I am incorrect I will glad to know that and let him know he was in fact correct.

Thank you in advance for any thoughts/input.


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## cgaston (Aug 15, 2017)

It is a stand alone document. 

from here:
https://www.aapc.com/blog/33092-operative-note-basics/


_A surgeon’s operative note should provide all the necessary documentation to describe the procedure performed. The note should “stand alone” as the only document needed to understand why the surgery was undertaken, and what occurred. The following documentation should be on every operative note:

Patient’s name
Date
Preoperative Diagnosis
Postoperative Diagnosis
Surgeon’s Name
Assistant Surgeon/Co‐Surgeon
Procedure
Indications for Surgery
Findings at Surgery
Include Post-Op Diagnosis in Operative Note
Whenever possible, try to differentiate the pre-operative and post-operative diagnoses. For instance, a pathology report can provide additional details that allow for a more precise post-operative diagnosis. You may also wish to report any underlying co-morbid conditions that can affect the surgical outcome_


I don't know how there is such a disconnect in a Surgeon's mind that they expect the highest reimbursement while providing the least amount of documentation for their services. It boggles my mind.


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## cgaston (Aug 15, 2017)

And one more from here:

https://med.noridianmedicare.com/we...ocumentation-guidelines-for-medicare-services

Providers billing Medicare for their services must act in accordance with the following conditions:


Document in appropriate office records and/or hospital records each time a covered Medicare service is provided.

When providing concurrent care for hospital or custodial care facility patients, physicians should identify their specialty where this helps support the necessity.

Write medical information legibly and sign each entry with a legible signature, or ensure that the provider's/author's/observer's identity is present and legible.

Medical information should be clear, concise, and reflect the patient's condition.

Progress notes for hospital and custodial care facility patients must have all entries dated and signed by the healthcare provider who actually examined the patient.

Provide sufficient detail to support the necessity for diagnostic tests that were furnished and the level of care billed.

Not use statements such as "same as above" or ditto marks ("). This is not acceptable documentation that the service was provided on that date.

The "burden of proof" remains with the provider to substantiate services and/or supplies billed to Medicare. During the audit process, if documentation is needed, the physician or supplier must provide the required documentation within the deadlines stipulated in the written request.


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## jdevilla (Feb 20, 2020)

The requirement for the Op Note was created not for coding purposes but is for quality and patient safety reasons. This is the main reason why this was originally a documentation requirement set forth by The Joint Commission and later on adopted by the Center for Medicare and Medicaid. 
Assigning a procedural code is based on guideline set by the American Medical Association. When it comes to where find the document, the OpNote I disagree is a stand alone document to look at; there is no where you can find such a strict guideline. The attached document is the CPT coding guideline from the AMA which basically provide sufficient information. Looking unto all documents from OPD consults, preadmission clinic consult, progress notes are part of the due diligence to navigate if the operative note is not enough. REMEMBER, Documentation requirement for OpNote is a quality and safety issue and not for reimbursement.

JdeVilla, MD
Commissioner, Healthcare Quality Commission


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## SharonCollachi (Feb 20, 2020)

jdevilla said:


> When it comes to where find the document, the OpNote I disagree is a stand alone document to look at



Why on earth would you want someone to dig through the entire medical record to find the information to code a surgery to bill it?


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## csperoni (Feb 20, 2020)

I can't speak to the legal requirements of it being a stand alone document, but I certainly have to echo Sharon's sentiment above.  
The coder should be able to read the 1 document (maybe also the pathology) and accurately code.  To suggest the coder should need to read pages and pages and pages of notes, would often take a coder longer to code the surgery than the surgeon to perform the surgery.  Regardless of whether or not it's legally required, it should absolutely be properly documented including the information required to accurately code.


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## jdevilla (Feb 20, 2020)

Go back to my original post, it says “if the opnote isnt enough”. In a perfect world it can happen however AMA instructions is more clear that it is not limited to the opnote.


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