Can you code the procedures listed in the OP Report or only from the narrative report in the body?
I am looking for clarification on this from anyone who is, or has experienced, this question at their facility. I've read "Learn how to read an Op report" and didn't find clarification on this. The coding staff at our facility is stating they can not code from the list of Operative Procedures performed in the surgeon's OP report unless they also state and describe these procedures in detail in the narrative body of their OP report. They are requesting that we query the provider in the instances where a procedure is not mentioned and detailed in the OP report and is only listed in the list of OP procedures completed.
Any guidance will be greatly appreciated!!
Any guidance will be greatly appreciated!!
Comments
Coding only from a Title or short op noteoften results in imprecise coding, The coding team needs to read the detailed body of each operative report. I can tell you that I too often will find that Stents (BM or DES) were employed during a LHC. However, the title of the LCH often will not state that significant CAD was found necessitating angioplasty w/ or w/o stents. Also, it is not unusual for the RN to note something significant such as VT as they document on the event log. To shift just a bit, one may advocate for the coding of dense adhesions with lysis of adhesions only noted within the body of an operative report or the body of the report may document something such as an iatrogenic tear or laceration.
P. Evans
CCDS