Health Information Management

Learn how to read an OP report

JustCoding News: Outpatient, April 18, 2012

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To correctly assign codes for any surgical procedure, coders need to have an operative (OP) report. But simply having an OP report isn’t enough. Coders also must be able to read the OP report and pick out the important information.

Coders also need access to the National Correct Coding Initiative (NCCI) edits as well as a diagram of surgical positions, said Lynn Pegram, CPC, CEMC,CPC-I, CGSC, lead coder and coding manager for a surgical practice in Richmond, Va., and principle consultant at Pegram's Coding4U. Pegram discussed general surgical coding during the AAPC National Conference in Las Vegas April 2-4.

Surgical package
Coders need to understand what is included in the general surgical package. These services are not separately billable and include:

  • Local infiltration, metacarpal, metatarsal, and digital block
  • Subsequent to the decision for surgery, one related evaluation and management (E/M) encounter on the date immediately prior to or on the date of the procedure
  • Writing orders
  • Evaluating patient in the post?anesthesia recovery area
  • Immediate post?operative care

Pegram also noted that these standards of medical and surgical practice are not separately billable:

  • Cleansing, shaving, and/or prepping skin
  • Surgical approach, incision, and lysis of simple adhesions
  • Insertion and removal of drains, suction devices, dressings, and pumps into the same site
  • Surgical closure
  • Pre?operative, intra?operative, post?operative documentation (e.g., photos, drawings, dictation, transcription)

Removal or release of simple adhesions is included in the general surgical package, Pegram said. If the physician documents removal of extensive adhesions or significant additional time required to remove adhesions, coders can add modifier -22 (increased procedural service) to the CPT® code.

However, physicians need to document more than just “extensive adhesions,” Pegram said. “They need to document the actual time because different doctors think different things are extensive.”

Coders need to understand what their payers require as far as documentation of additional work and also how the payer wants the modifier reported. Some payers don’t accept all modifiers or require specific words in the documentation. Others may have specific time requirements for use of modifier -22, Pegram said.

Each facility or practice should have some type of guidelines for what is considered additional work. Pegram often appends modifier -22 and does receive additional payment. However, she does not append it unless the physician documents at least one hour of additional work.

Anatomy of an operative report
Coders will generally see certain elements in all OP reports, so it helps to understand what those elements are.

The pre-operative diagnosis is the reason the patient is in on a particular day. Don’t code from the pre-operative diagnosis, Pegram warned. The pre-operative diagnosis is not necessarily the reason for all the procedures the physician performed during a visit. It is why the patient has now presented for the planned procedure.

The post-operative diagnosis provides the following information:

  • Why the procedures were performed
  • What the physician discovered during the operation
  • Where the physician performed the work

Make sure you code from the post-operative diagnosis, Pegram said. Sometimes both are the same, but not always. In addition, the physician may need to perform additional procedures based on what happens during the planned procedure.

The title of the procedure is a brief description of what procedures the physician performed and helps coders know what is going on. This should be a total listing of what the physician did, but does not determine whether the item can be coded and billed, Pegram said. Coders should never code from the title of the procedure.

Coders will also find a notation of the anesthesia used during the procedure:

  • General
  • Regional
  • Moderate (i.e, conscious) sedation

Some CPT codes actually specify the type of anesthesia included in the procedure and the CPT Manual also includes an icon for codes that include conscious sedation as part of the procedure.

For example, if a physician inserts a non-tunneled centrally inserted central venous catheter into a patient younger than age 5 (code 36555), the conscious sedation is included and cannot be billed separately.

Coders should also review the indications sections of the OP report to answer these questions:

  • What disease/injury/condition created the need for the surgery?
  • Is there any indication that the patient is subject to an existing global period?
  • Are there indications that this may be a more difficult procedure?

Unfortunately, physicians don’t always document indications well, especially whether the patient underwent any prior procedures. Pegran said she will often pull up a patient’s complete record to determine if the patient is in the global periods for another procedure.

Procedure note provides the details
The largest section of the OP report is the procedure note. This is where the physician documents the specifics of what he or she did. The physician should clearly outline all procedures performed and provide details including:

  • Patient position
  • Approach
  • Anatomic site
  • Depth
  • Findings

Physicians don’t always specify the approach, but coders can look for certain key words to tell them what approach the physician used. For abdominal procedures, physicians can choose an open or laproscopic approach. Coders shouldn’t assume an approach based on the title of the procedure, they should look to see what the physician actually did.

For example, if coders see the words “insufflated abdomen” they know the physician is performing a laproscopic procedure even if the physician doesn’t say laproscopic approach. The only reason to insufflate the abdomen is for laproscopy.

The physician should document any misadventures or complications, as well as any abnormal findings, Pegram said. This is also where the physician should document the time for procedures that require additional work.

The physician should include any of the following in the procedure note:

  • Excision
  • Biopsies
  • Lesions
  • Foreign bodies
  • Anastomoses
  • Tubes placed for drainage or feeding
  • Hardware used as part of repair
  • Grafts
  • Blood loss

The physician should also report the type of closure with enough detail to support any additional coding for an extensive repair, Pegram said.

Tips for coding common general surgical procedures
As part of her presentation, Pegram reviewed a number of operative reports and provided some tips and items to look for with a variety of procedures.

For example, if a physician is repairing a hernia using mesh, coders need to determine the approach before they can decide whether to report the mesh separately. Mesh is included with a laparoscopic hernia repair, but not with an open repair.

Physicians also need to specify whether a hernia is manually reducible. A hernia is only considered incarcerated if the physician cannot reduce it manually, Pegram said. Coders can’t assume or guess. If the physician didn’t document it, query the physician.

For some bowel resections, the physician will need to take down the splenic flexure to join the ends of the colon. The splenic (or left colic) flexure is a sharp bend between the transverse and the descending colon in the left upper quadrant. CPT does include a code for mobilization of the splenic flexure (code 44139), but the physician must clearly document the splenic flexure mobilization.

For hemorrhoid coding, the physician must document where the hemorrhoid originated: internally or externally. Code selection depends on location and type of ligation. Coders can report internal, external, or internal and external hemorrhoids.

For breast procedures, coders must differentiate between a simple mastectomy and a modifier radical mastectomy, Pegram said. A simple mastectomy means a total mastectomy. The physician may biopsy the sentinel lymph nodes to determine whether the cancer metastasized.

Keep in mind that sentinel nodes are always deep, Pegram said. So look for documentation of exactly how deeply the physician dissected. If the physician biopsied superficial lymph nodes, report CPT code 38500 (biopsy or excision of lymph node[s]; open superficial) or code 38505 (biopsy or excision of lymph node[s]; by needle superficial).

Report CPT code 38525 (biopsy or excision of lymph node[s]; open, deep axillary node[s]) if the physician documents “deep” sentinel nodes or true axilla, Pegram said.

Regardless of what general surgical procedure a physician performs, coders should look for certain elements in the documentation. They must remember to read the complete OP report and shouldn’t code only from the summary or title of the procedure. If the physician doesn’t document all of the necessary information, query the physician.

Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at

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