Learn What Makes a Good Op Note -- and Correct the Bad
Published on Mon Jul 16, 2007
What to do when hysterectomy note fails to specify vaginal or abdominal
When you-re coding hysterectomy reports, you cannot rely on the procedure's title. You must read the entire note carefully and highlight what the physician actually did. If you can't determine these things, you-ll have to ask your physician for more information.
To find out what makes a bad and good note and what to do about it, compare these two hysterectomy op reports and read the advice that follows. Rate This Op Note Preoperative diagnosis: Uterovaginal prolapse
Postoperative diagnosis: Uterovaginal prolapse
Operation: Hysterectomy; anterior and posterior repair
Procedure: The ob-gyn placed the patient in a lithotomy position and prepped the perineum and vagina in the usual sterile manner. The ob-gyn placed a tenaculum on the lip of the cervix and entered the cul-de-sac. He pushed the bladder off the cervix and the lower uterine segment. Then he entered the anterior cul-de-sac.
He clamped, cut and ligated both uterosacral and cardinal ligaments and the uterine vessels. He inverted the fundus of the uterus and then clamped, cut and tied the adnexal structures. He closed the peritoneum with a pursestring suture. He repaired the cystocele.
The procedure was concluded, and he inserted the vaginal packing. The patient tolerated the procedure, and the ob-gyn sent her to recovery in good condition. Determine What You-re Missing
In this example, you-re missing vital information. For instance, can you tell if this is a vaginal or abdominal hysterectomy? Do you know if this is truly an anterior and posterior repair? The physician mentions that he does the repair, but he doesn't say that it's an anterior and posterior repair. He also doesn't say whether he removed the ovaries or tubes.
A bad procedure note leaves the coder with questions because the documentation does not resolve contradictory or conflicting information. -This can lead to a loss of payment or even overpayment,- says Christine Dubois, CPC, coding/compliance coordinator for Baystate OB/GYN in South Hadley, Mass.
Action steps: Get clarification from the physician immediately. -Doctors tend to forget that if it's not documented, it's not done,- Dubois says.
Good idea: Also, you may want to ask an experienced coder to explain what your ob-gyn generally does during a hysterectomy, so you-ll learn more about the procedure and what should be in the note. Try Ranking This Second Op Note Preoperative diagnosis: Uterovaginal prolapse
Postoperative diagnosis: Uterovaginal prolapse
Operation: Vaginal hysterectomy; anterior and posterior colporrhaphy Procedure: Under general anesthesia, the ob-gyn placed the patient in a lithotomy position. He prepped and draped the perineum and vagina in the usual sterile manner. He placed a tenaculum on the posterior [...]
