Wiki Not stating surgery performed in the post-op note

[michele1me@yahoo.com]

My physician saw a patient in the office for a post op visit. The patient had a major surgery. No where in the post-op note does he state what the surgery was. Is it necessary to state the surgery that was done in the HPI? I thought it was. He describes in the Exam that staples were removed and part of the incision was slightly open with drainage noted.

 

[thomas7331]

From a coding perspective, if you are billing for this service, then you would likely need that information in the note in order to be able to properly code the visit and to support the charges since the note should stand on its own. But if this is within the global period and there is no charge, I don't see why this would be a problem. The surgical report would be in the patient's chart already, and if there were ever any question as to what surgery was done, that is a part of the record and could be referenced if necessary.

 

[michele1me@yahoo.com]

Ok, that sounds great! Thank you!