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trishs

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We have an issue with a provider.

This provider is of the opinion that we should not be coding his surgery from the body of the Op report, but from the description of the procedure.

I have been on the CMS website to try to determine the Federal Guidelines, but have been unsuccessful.

Does anyone have any suggestion as to where this guideline might be found?

Thanks for all of your help and support.
 
Hello:

You should always code from the body of the op note. The procedures mentioned in the beginning of the note must match the body of the op note.

I code vascular and interventional radiology op notes everyday and on rare occasions, the procedures performed will not be dictated within the body. I ask my physicians to add an addendum (if performed) to include the full procedure performed.

I like to review the procedures performed first then find the actual performance of it within the body of the op note.

Hopefully that helps!
 
I'm not really sure where you can find what you are looking for, it is a very basic thing though.

This link to an MLN matters explains rejection codes, some of which are for operative report issues. The fact they can reject a claim based on the op report and not just the header, to me, supports that you must code from the op report itself.

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6229.pdf

page 7.

Hope this helps and I will keep my eye out for anything else that might spell it out better.

Laura, CPC
 
So ...

So if the TITLE of the op note says "Amputation above the knee" and the body of the report is for an appendectomy we should code the amputation?

I know that's an extreme example, but it's the principle behind the rule to code form the body of the report.

F Tessa Bartels, CPC, CEMC
 
FTessaBartels said:
So if the TITLE of the op note says "Amputation above the knee" and the body of the report is for an appendectomy we should code the amputation?

I know that's an extreme example, but it's the principle behind the rule to code form the body of the report.

F Tessa Bartels, CPC, CEMC
Click to expand...


LOL Tessa!!! I Love it!! you are absolutely right though.

The body of the report needs to support the header :)
 
Great response Tessa!

Imagine......if we only had to code from the "procedure" line on those OP reports, how much easier our job could be (Hee! Hee!).

Due to my disbelief, I actually had someone in a position higher than mine once tell me that if a doctor (who has been doing these certain types of
procedures for a long time) says in the procedure line that it did "this", that I should code "this". The body of the OP did not refllect it and I did not code it.
 
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