General Surgery Operative Note

Hello. I am interested in other General Surgery coder's opinions on whether or not they feel it is "permissable" or even legal to code out a laceration repair with the measurements being listed ONLY in the H&P, or other E&M format?

I personally think the exact measurements need to be listed in the operative note to validate and substantiate the code selection, yet one of the surgeons I work for is insisting that as long as she has listed them somewhere previously, that I can choose the code based upon that and she doesn't feel it is needed in the operative note.

Your thoughts anyone?

Thank you and I can be reached back by email at FlorkeLP@stlukes.org

and welcome any feedback with regulation references to back your opinion up.

Linda F.

re: General Surgery Operative Note

Of course we would prefer the length to be listed in the Operative note. But, if listed in the E/M document from the same date of service, it is in the medical record, and can be used to support the CPT® code billed.

It wouldn't be much more work for the surgeon to repeat it, but it isn't much more work for us to look it up in the second document.

What do others think?

re: General Surgery Operative Note

I agree, I would rather have a separate procedure note but if documented on same day of service in E/M note , would be acceptable.

re: General Surgery Operative Note

I personally don't have an issue with reporting the code as long as the lenght is documented whether it is in the E/M or H&P. I like many coders, prefer to do whatever necessary to make my providers day easier and if that means I have to check multiple places in the medical record to validate their code selection, I will gladly do it. Of course I would prefer the length present on the OP for my convenience as well as the convenienc of the insurance company who may request or require the operative report for claims processing but, I can search it out and my doctors appreciate that effort.