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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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How would you code an operative report?
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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