How Would You Code An Operative Report?


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How to Code from an Operative Report
There is no quick way to code an operative report. You must read and reread the
report to be sure your coding reflects all the procedures and diagnoses contained
in the report. To code only the “preoperative diagnosis, postoperative
diagnosis, and operation performed” as listed at the beginning of the operative
report would be incorrect. Additional procedures/diagnoses may be identified
in the body of the operative report that are not indicated in the information
provided at the top of the form. By coding directly from the text of the operative
report, you will ensure that your coding reflects the procedure(s) actually
performed, as well as the diagnosis(es) related to the procedure(s).
It is essential to communicate with the surgeon whenever you have a question
about a procedure or the diagnosis related to it. You may also need to refer
to other portions of the patient's chart, such as the pathology report or history
and physical examination, to correctly code the diagnosis for which a procedure
was performed. For example, the pathology report will indicate whether a lesion
that was removed was benign or malignant. Be sure to follow official ICD-9-CM
coding guidelines for coding and reporting when assigning diagnosis codes.
Official guidelines for coding and reporting ICD-9-CM are available from the
Central Office on ICD-9-CM at the American Hospital Association (phone
number: 312 422-3000).

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