As a Medical Coding Professional, when you sit down to code an open procedure, you need to see the operative report, which includes the following:
A heading that identifies the patient, the date and location of the surgery, the physician, and other demographic information.
The first step in abstracting the billable codes from the medical record of an open procedure is to identify which body part was treated and why. After you have identified that, you know which area of the CPT book to check to begin the process of coding.
A preoperative, or preliminary, diagnosis, which is the diagnosis based on preoperative testing and pertinent physical findings observed by the physician during the examination
The postoperative, or definitive, diagnosis, which is what the physician confirmed during the surgery.
A summary or outline of the procedures performed.
Do not code procedures from the outline in the report! These headings are merely previews of what is to come. Regardless of what the heading says, for a procedure to be eligible for reimbursement, it must be documented in the body of the report.
A full report containing the surgeon’s description of everything that he did during the operation.
The documentation for the procedure should always be described in the body of the report. If the body of the report does not contain something that is mentioned in the heading, then the physician must correct the documentation before it can be reported. Remember the mantra of the medical coder: “If the doctor didn’t say it, it wasn’t done.”