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Tip: Correctly code from op reports

Ambulatory Surgery Reimbursement Update, May 14, 2008

When you are coding surgical procedures it is very important to read the entire op report for each procedure performed. This is the only way to ensure that you capture and code each and every procedure performed during an operative session. Do not just code from or rely on the summary statements or listing of the surgery titles at the beginning of the report. Likewise, you should not code from Superbill or Chargeticket documents. And never code from the surgery schedule without having the op report in hand!

Also, you should never code a bill for a procedure you are unsure took place (i.e., the case was scheduled but cancelled).

Medicare’s guidance states that you may only code and bill for the procedures documented in the body of the op report. If you are fairly certain that a physician performed a certain procedure but neglected to document it in the body of the report, you may confirm the occurrence of the procedure by using the pathology report. If you do so, you should request that the surgeon do an official addendum to the op report to correct it. Addendums are to be referred to as such, and the physician should date an addendum with the date he or she amends the record. This is not necessarily the surgery date. The surgeon must sign the addendum and placed it with the original op report in the chart record.

This tip is brought to you by Ellis Medical Consulting, Inc.

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