Indications for Surgery Paragraph

Indications for Surgery Paragraph

April 11, 2019

Question:
I recently attended a coding course you taught and learned a lot – thank you! I will say though that I am slightly confused by one thing you said… a history in the op note? I have never put any history in an op note.   Where do you put any kind of history?

Answer:
Thank you for your kind words – it was great working with your group.

Yes sir – an Indications for Surgery paragraph provides the medical necessity and a brief history of the patient’s illness so anyone reading the operative note understands the context in which the procedure was performed.  We must send in the operative note when there is a dispute with a payor about the claim for surgery – we don’t send in the H&P, or office notes, etc.  Therefore, the surgery note should stand alone to support the medical necessity for the surgical procedure/codes.  Also, the operative note is the documentation which communicates with other health care professionals about what has been done to the patient and why – so it should provide a summary of the reason why the patient is having surgery.

*This response is based on the best information available as of 4/11/19.

 

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