Can anyone help me with this question? I code anesthesia for a Boston hospital and I am fairly new at this. I am being told that I don't need an op note to do my coding. I was told that because it is "only anesthesia" I can just take whatever the OR schedule states as the procedure. My problem is that the OR schedule doesn't give diagnosis codes and the procedure listed is not always accurate. Can anyone tell me if there is a specific policy on this?
Lynda
Lynda