Case Study:
Clearly Written Op Note Allows Billing for More Procedures
Published on Wed Mar 01, 2000
"When a general surgery coder reads the top of a surgeons operative note that lists a left hemicolectomy, along with repairs of umbilical and incisional hernias, insertion of mesh and insertion of right subclavian IV, she knows both hernias normally are bundled into the hemicolectomy. But by reading the entire op note before filling out the HCFA 1500 claim form, she finds that each of the procedures is separately billable.
In the following operative report, the coder finds a carefully documented description of the surgical procedures that allows her to bill for the incisional hernia and the insertion of mesh because the notes clearly document that separate incisions and repairs were performed during the surgery. This highlights the importance both of reading the entire operative note on the part of the coder and clear documentation by the surgeon.
Operative Report
Preoperative Diagnosis: Polyp, descending colon, umbilical hernia and incisional hernia; poor peripheral veins
Postoperative Diagnosis: Polyp at the splenic flexure, umbilical hernia, incisional hernia; poor peripheral veins.
Procedures: Left hemicolectomy, repair of umbilical hernia, repair of incisional hernia with insertion of mesh; incision of right subclavian IV.
Pathology Report: Pathology for the hemicolectomy returned as villous adenoma with atypia.
Estimated Blood Loss: 200 cc.
History: This 83-year-old female presented with an umbilical hernia and incisional hernia from a CABG incision; she also was found to have a rectocele. She subsequently had a colonoscopy that identified a broad-based polyp in the descending colon. She presents now for resection of the colon lesion and repair of the umbilical and incisional hernias.
Operative Procedure: Under satisfactory general endotracheal anesthesia and the patient in the Trendelenburg position, the chest was prepped and draped. The skin lateral to the junction of the clavicle and the first rib on the right side was infiltrated with Xylocaine and a small incision made. A thin wall needle was passed into the subclavian vein and a guidewire advanced. Fluoroscopy showed the wire to be in the chest. The dilator followed by the Arrow triple lumen catheter were threaded over the guidewire and the tip of the catheter positioned at approximately the superior portion of the right atrium. This was then sutured in place at about 14 cm using the attachable hub. Betadine followed by an occlusive dressing was applied.
With the patient in the lithotomy position, the abdomen and perineum were prepped and draped. A midline incision was made and the abdomen entered. Initially, I was trying to keep the colon resection incision separate from the repair of [...]
