betsycpcp
Networker
I am reviewing an op report where the surgeon has apparently used a pre-written report for rotator cuff repair, subacromial decompression, etc. In the main body of the op report, he has statements such as "if the rotator cuff repair was necessary, the arthroscope was reinserted in the posterior portal..." etc. Then at the end of that paragraph it says "Any deviations from this description are noted below." There are no notes below of any "deviations," but the "operative findings" section at the start of the report says the rotator cuff didn't have a full thickness tear. It doesn't say that they did anything to the RC, but it also doesn't say they decided not to do anything to it.
I work for a payer, and we haven't received the bill from the surgeon yet, but we were asked by the surgeon's office to approve 29823, 29826 and 23700. Another coder took the op report to mean that they did a rotator cuff repair, since they described one, but the surgeon's office said no, they did what was in the operative findings section, and that's what they code from. They said the body of the report lists things that might have been planned, and you have to look at the findings to see what was actually done. ???!!
I have never encountered an operative report for major surgery where they describe what they might have done and say any deviations will be described somewhere else in the report. We do see reports for epidural injections, etc where they use a preprinted report and fill in blanks or cross out things that weren't done.
The hospital appears to have coded based on the operative findings section- they didn't bill 29827.
Is anyone familiar with this type of report being used? It's a final draft, as far as I can tell. I find it hard to trust what I'm reading.
I work for a payer, and we haven't received the bill from the surgeon yet, but we were asked by the surgeon's office to approve 29823, 29826 and 23700. Another coder took the op report to mean that they did a rotator cuff repair, since they described one, but the surgeon's office said no, they did what was in the operative findings section, and that's what they code from. They said the body of the report lists things that might have been planned, and you have to look at the findings to see what was actually done. ???!!
I have never encountered an operative report for major surgery where they describe what they might have done and say any deviations will be described somewhere else in the report. We do see reports for epidural injections, etc where they use a preprinted report and fill in blanks or cross out things that weren't done.
The hospital appears to have coded based on the operative findings section- they didn't bill 29827.
Is anyone familiar with this type of report being used? It's a final draft, as far as I can tell. I find it hard to trust what I'm reading.