Wiki Indication for Procedure

[racosta]

Does anyone know if Medicare requires there to be an "Indication for Procedure" listed on the op report? If so, would "Please see my History & Physical" suffice? We haven't had any issues but I would like clarification and supporting documentation of there is any out there.

Thanks.

 

[dpage77]

I don't quite understand what you are trying to determine? The diagnosis you use should support the procedure you are doing.

 

[racosta]

I am trying to determine if there are guidelines for op report documentation. It's like using SOAP for E/M documentation.

 

[member7]

Usually op reports contain the name of the procedure and the operation itself. I agree with you to put a notation on the op report. If you were audited, you would be expected to provide the history and physical and any other supporting documentation.

 

[007CPC]

Does anyone know if Medicare requires there to be an "Indication for Procedure" listed on the op report? If so, would "Please see my History & Physical" suffice? We haven't had any issues but I would like clarification and supporting documentation of there is any out there.

Thanks.

Hi racosta:

I think the phrase 'indication for procedure' is another way of CMS saying the coder should code to 'medical necessity' or 'the dictation needs to contain ample documentation outlining why the procedure is trying to recieve reimbursement'.

Maybe a more adroit coder could weigh in to describe the implications of this "Phrase"!