March 14, 2019
If I do a cosmetic rhinoplasty and a functional septoplasty on a patient, should I document both procedures on the same operative note? Or should I document a separate operative note for each procedure?
Good question! In KZA’s experience, it is best to document one operative note for all procedures performed on the same patient, at the same operative session, on the same day under the same anesthesia session. This is similar to the nurses’ operating room (OR) record and the anesthesia records being single (not separate) documents that reflect both the cosmetic and functional procedures.
There is no reason to eliminate the cosmetic portion of the procedure from operative note or document two op notes. Just be sure to specifically document in the operative note when the functional procedure started and stopped as well as when the cosmetic portion of the procedure began and ended much like the OR nurse and anesthesiologist will in their notes. Obviously, the OR and anesthesia time for the cosmetic procedure will be covered by the patient’s personal payment for the rhinoplasty. We would expect insurance to cover only the OR and anesthesia time, as well as the surgeon’s fee, for the functional septoplasty. The patient pays cash for the cosmetic procedure surgeon’s fee, anesthesiologist’s fee and OR time as well as other charges associated with the cosmetic portion of the procedure.
*This response is based on the best information available as of 3/14/19.