General Surgery Coding Alert

General surgeons should include a short section in their op notes that explains what they found, what they did and why they did it, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs executive committee. Although physicians have very good reasons for performing certain procedures, that information may not be as obvious to others, Eisenberg says, noting that office staff, carriers and other doctors all benefit if the op note contains a Findings section.

Physicians make a lot of intuitive decisions that others may not follow. A findings section would help othersyour own staff, reviewers at the carrier and even other physiciansunderstand your thinking and the procedure quickly, he says. The detailed information usually reported in the body of operative reports is not as important as what the surgeon found.

There is too much extraneous material in the body of the op note, Eisenberg says. Nobody cares what suture you used to tie off a blood vessel. Whats important is why you tied off the blood vessel.

Such a section need not be long: One or two paragraphs usually is enough to describe the findings that implicitly match what the otolaryngologist performed surgically, Eisenberg says.

Pathology Provides Important Information

The Findings section should describe what the pathology was at the time of surgery. If thats done appropriately, it will explain why the procedures performed were chosen, he says.

For example, when a surgeon abandons a laparoscopic appendectomy (44970) and converts to an open procedure (44950), the findings section might say: Findings: There was intense inflammation involving the cecum and terminal ileum, the appendix was obliterated. When attempt at mobilization was made, an abscess was discovered. For these reasons an open procedure followed. This short paragraph explains what the surgeon found (an abscess and intense inflammation making dissection and anatomic identification impossible). It notes what the surgeon did to correct the problem (the conversion to an open procedure) and, by adding three wordsfor these reasonssuccinctly explains why the laparoscopic approach was abandoned.

In another example, a surgeon performs a splenectomy, repair of small bowel injuries, and an end colostomy with formation of a mucus fistula for a GSW to the abdominal left upper quadrant.

A good findings section might read: There was extensive tissue destruction and clot. The injury to the spleen was in the hilum and there was widespread gross fecal contamination from the penetrating injury to the splenic flexure as well as two small bowel perforations. Because of the splenic hilum injury, the spleen had to be sacrificed and with the extensive colon trauma and gross contamination, a colostomy was elected. (This explains why the spleen was removedbecause removing the spleen [...]