Ophthalmology and Optometry Coding Alert

Question: I'm filing a revised operative report. Should I keep the original incorrect report in the chart and label the new correct report as revised, or should I remove the incorrect report and submit the new one, still listed as revised?

Louisiana Subscriber

Answer: Make it a rule always to be sure to keep the original report in the chart! Once signed, the original report should be kept as documentation of the doctor's original dictation. Some practices stamp these original reports to classify them as "copy" only. This organizational method may help you to keep track of the drafts of your reports a sometimes daunting task because the physician often corrects or adds details to the unsigned report or transcribed note.

After the physician's changes are incorporated into a final revised version of the report, the physician has signed the report. And this revised report should be in the chart as well. You should double-check for your physician's signature.

At the bottom of the revised report, you should include the transcriptionist's notation, the date of revision, and the typed statement "Patient went to the operating room in good condition."

Answers to You Be the Coder and Reader Questions provided by L. Heath Pridgeon, clinical and reimbursement specialist at an ophthalmology clinic and ambulatory surgery center in Florida; and Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.