Wiki Coding from surgical report

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REGINALD068

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Good evening All: The help I recd regarding Anesthesia coding really helped refresh my memory, especially since I never had the opportunity to use it. I need help with something else now. Does anyone know the list of key terms that's used to assist in finding what the procedure being performed is? I haven't coded from surgeries in quite a while, and need some assistance. Thanks!
 
Components of an operative report:

  • Preoperative diagnosis - tentative diagnosis before surgery
  • Postoperative diagnosis - diagnosis after the surgery has been performed
  • Surgical procedure - concise statement of the procedure(s) performed
  • Indications for procedure - facts leading up to the decision for the surgery
  • Details of procedure - narrative detailed description of the surgical procedures
  • Signature of surgeon

    Common Procedural Terms of Method or Technique:
    • Incision
    • Excision
    • Destruction
    • Amputation
    • Introduction
    • Endoscopy
    • Repair
    • Suturing
    • Manipulation

    Also pay attention to the approach for example: Did the surgeon access surgical site throught the umbilical or the thoracic?


    Sample of questions to ask yourself to help determine a code (for example, removal of a lesion):
    • Was the lesion benign or malignant?
    • What technique was used to remove the lesion (laser, excision, or shaving)?
    • Where was the lesion?
    • Were there any additional procedures performed, such as intermediate wound closure?
    • What was the excised diameter (greatest clinical diameter) of the lesion?


    I could go on and on but I would probably be typing for hours.:) Pay strict attention to the guidelines for sequencing and modifiers.
 
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