Indications for Surgery Paragraph

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October 18, 2018

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.  Here is an example – an operative note was sent to the insurance company because a payment denial was received.  Because there was no Indications for Surgery paragraph, the auditor had no idea that the patient hit himself in the face with a wrench which caused the infection and subsequent abscess being treated.  Therefore, the auditor again denied the claim requesting further information.  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.  The surgery note should stand alone to support the procedure/codes you’re billing for surgery.  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 10/18/18.

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