September 6, 2018
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 record and the anesthesia record being single (not separate) documents that reflect both procedures.
Be sure to 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. Obviously, the OR and anesthesia time for the cosmetic procedure will be covered by the patient’s personal payment for the rhinoplasty. We expect insurance to cover only the OR and anesthesia time, as well as the surgeon’s fee, for the functional septoplasty.
*This response is based on the best information available as of 09/06/18.