Front-Back Surgery and Two Operative Notes

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Question:

I recently heard at a coding course that each approach by the spine surgeon should have a separate operative note. For example, anterior and posterior procedures on the same day require separate operative reports. I’ve never heard this before. What is your advice?

Answer:

While the two procedures might require separate approaches, the fact is that both procedures were performed on a single patient under a single anesthetic at a single operative session. Therefore, a single operative note is appropriate.

It can be very confusing for billing office staff to know which operative report to send, if two are dictated, when appealing denials. Also, oftentimes we see no information in the first or second operative report describing the patient being turned or re-prepped for the second procedure. This creates confusion for the coders because they don’t know to seek out the second operative report for coding purposes.

For all the above reasons, KZA has always recommended dictating one operative report when performing front-back surgery on the same day.