Health Information Management

Tip: Review indications for surgery in operative report

APCs Insider, August 3, 2012

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Coders should review the indications section of the operative 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 the planned procedure may be a more difficult procedure?
Unfortunately, physicians don't always document indications well, especially whether the patient underwent any prior procedures. Consider pulling up a patient's complete record to determine whether the patient is in the global periods for another procedure.
 
The tip is adapted from “Coders need to learn to read an operative report” in the June Briefings on APCs.



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