TnRushFan
Networker
Hey folks, I have been a Surgery Coder for a long time and know this is going to sound like a really simplistic question...but I need something in writing to back me up and defend my coding with the auditing service...I want to be prepared.
Does anyone have any references / opinions on what constitutes surgical documentation?
When I went to coding school (many years ago)...I was taught that for Surgical Professional Fee coding we only code what pertains to the immediate surgical encounter. Can only glean information from brief op note, op note, operative path, operative imaging, and surgical H&P if written within 48 hours. We have a new auditing service and they are assigning errors for not coding diagnosis codes from progress notes. This has not been an issue until recently...and I disagree with this philosophy.
Surgery Coders should only code what is happening in the operating room during the surgery being performed...what they are doing and why. If the surgeon is operating on it, he/she needs to document it in the op note.
Any thoughts will be greatly appreciated...and any references too.
Thanks in advance.
Does anyone have any references / opinions on what constitutes surgical documentation?
When I went to coding school (many years ago)...I was taught that for Surgical Professional Fee coding we only code what pertains to the immediate surgical encounter. Can only glean information from brief op note, op note, operative path, operative imaging, and surgical H&P if written within 48 hours. We have a new auditing service and they are assigning errors for not coding diagnosis codes from progress notes. This has not been an issue until recently...and I disagree with this philosophy.
Surgery Coders should only code what is happening in the operating room during the surgery being performed...what they are doing and why. If the surgeon is operating on it, he/she needs to document it in the op note.
Any thoughts will be greatly appreciated...and any references too.
Thanks in advance.