Tasks a Medical Coder Does to Prepare a Billing Claim for Submission

The job of coder starts with the documentation provided by the physician. This documentation can take the form of an operative report or an office note.

Physicians are trained to document their work, so consider them partners in the coding enterprise. They (or a member of their staff) note all the information needed to treat a particular patient before the paperwork hits the coder’s desk.

Check operative reports

An operative report is the document that is transcribed from the physician’s dictation of the patient encounter. It describes in detail exactly what was done during the surgery. Operative reports are normally set into a template, which serves as an outline that identifies the reason for the procedure, what illness or injury was confirmed during the procedure, and finally the procedure(s) that were performed.

The basic format of an operative report includes the following:

  • Patient name and date of birth

  • Operating physician

  • Date of service

  • Preoperative diagnosis (the diagnosis based the examination and preoperative testing)

  • Postoperative diagnosis (the diagnosis based on what the doctor found during the surgery)

  • Procedure(s) performed (an outline of the procedures done)

  • Body of the operative report (a description of everything that was stated in the postoperative diagnosis and procedure performed sections)

Put simply, verifying documentation is a fact-checking gig. Here’s what you need to check:

  • That procedures stated as performed in the heading of the operative report are substantiated in the body of the report.

  • The diagnosis provides medical necessity for the procedure and that the procedure(s) listed in the outline are documented in the body of the operative report. Medical necessity is simply the reason for the visit or surgery; it defines the disease process or injury. Before payers reimburse the provider, they have to know why the visit was necessary.

As a coder, you rely on the information in the body of the operative report to verify the documentation. If the body doesn’t support the rest of the operative report (the operative report doesn’t mention a procedure listed in the procedures performed section, for example, or the description isn’t detailed enough), then you’re responsible for asking the surgeon to clarify.

Remember: If the doctor doesn’t say it in the operative report, regardless of how obvious it seems, it was not done.

Check office notes

All physician services are coded and billed based upon physician documentation. When coding office procedures or verifying the level of evaluation and management code that is appropriate for the visit, you rely on the physician’s office notes. An office note typically documents the patient’s symptoms, the physician’s findings, and the plan for treatment, including a follow-up plan.

If you believe that a higher level of service was performed, asking a physician for clarification is certainly acceptable, but coding a procedure that’s not documented is not acceptable. Coding is not a job for those who like to second-guess.

You can’t assume you know what the doctor meant or intended and code based on your assumptions. Therefore, make sure you add “clarifying information” to your list of daily jobs as a coder.

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