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May 8th, 2018 - stepyg

Opertative Report

Can someone show me how to dissect and code a op report. I have trouble knowing what I need to code. An example is attached:

Clinical Record
PATIENT: Shellie Smith
SEX: FEMALE
Age 24
Private Payer (Medicare rules for 65 and older)

DATE OF OPERATION: 1/1/20XX

PREOPERATIVE DIAGNOSIS: CHRONIC PELVIC PERITONITIS ABSCESS.

PROCEDURES: EXPLORATORY LAPAROTOMY WITH DRAINAGE OF PERITONEAL ABSCESS, ABDOMINAL WASHINGS.

POSTOPERATIVE DIAGNOSIS: CHRONIC PELVIC PERITONITIS ABSCESS.

SURGEON: Rex Andrews, M.D.

ANESTHESIA: GENERAL, ENDOTRACHEAL.

ESTIMATED BLOOD LOSS: 400 CC.

WOUND CLASS: CLEAN AND CONTAMINATED.

SPECIMEN: PERITONEAL CULTURE.

PATIENT'S CONDITION: INTUBATED TO SICU STABLE.

FINDINGS: 200 cc of foul smelling yellowish green pus upon entering peritoneal cavity an abscess was found,this has been an ongong problem, made a low transverse uterine incision to the posterior aspect of the bladder with multiple loculations. Uterus was about 10 to 12 week size. Normal tubes and ovaries bilaterally. No signs of bladder or bowel nor posterior cul-de-sac involvement and no hemoperitoneum
with normal appendix visualized. Excellent hemostasis. Drain applied, from lower pelvic cavity, with minimal drainage noted post procedure, Smead-Jones closure, wound left open for closure by secondary intention. The patient was consented and before taking to the operating room told of risks, benefits and alternatives and the risks and benefits to
the alternatives.

PROCEDURE: Once this was signed and agreed to procedure, she was taken to the operating room where she was placed in dorsal lithotomy position. General anesthesia was then placed and found to be adequate. The patient was
prepped and draped in usual sterile fashion.

A Pfannenstiel skin incision was made over the previous scar as the patient had clearly asked that a vertical scar not be made. Once a Pfannenstiel incision was made with a scalpel, it was carried down all the way to the fascia and dissected bilaterally. The fascia was then incised using the scalpel and carefully dissected to both lateral ends.

At this point, upon entering the peritoneal cavity, copious amount of foul smelling yellowish green pus amounting to
approximately 200 cc emanated. Culture was obtained without evidence of hemoperitoneum. The incision was again extended laterally and a Maylard incision was performed through rectus muscles. Upon obtaining appropriate exposure, the loculations were noted and were broken up followed by copious irrigation with attention to hemostasis on all surrounding structures. The uterus was noted to be 10 to 12 week size with normal tubes and ovaries bilaterally. Posterior aspect of the uterus was freed of any adhesions and no evidence of abscess formation. The rest of the sigmoid was grossly normal upon examination. The appendix and upper abdomen were visualized and grossly normal.

.Attention was placed towards the peritoneum muscles all of which appeared viable without any signs of necrosis and
subsequently they were both approximated with excellent hemostasis. The fascia was inspected and found to have clear margins, which were then reapproximated and closed with a Smead-Jones closure. Irrigation again was applied and bleeding points were cauterized. Wet dressing applied, drains secured and abdominal bandage and bindings
were applied.

All sponge and total lap counts were correct x 2. The patient was cleaned and taken to the SICU intubated where she was deemed to be stable.

Rex Andrews, MD

Electronically signed by REX ANDREWS, MD 1/1/20XX

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May 23rd, 2018 - MargeM   11 

re: Opertative Report

Here are the steps that I have used when I teach coding:

Steps to Code an Op Report

Step 1. Review carefully the listing of procedures performed (located in the outline section of the report).

Step 2. Read the body of the report and make a note of the procedures you would expect to code.

Step 3. Identify main term(s) and subterms for the procedure(s) to be coded.

Step 4. Underline and research any terms in the report that you cannot define.

Step 5. Locate the main term(s) in the CPT Index. Check for the proper anatomic site or organ.

Step 6. Research all suggested codes. Read all notes and guidelines pertaining to the codes you are investigating. Watch for “add on” procedures described in any notes/guidelines.

Step 7. Return to the index and research additional codes if you cannot find a particular code(s) that matches the description of the procedure(s) performed in the operative report.

Step 8. Investigate the possibility of adding modifiers to a specific code description to fully explain the procedure(s) performed.

Step 9. Code the postoperative diagnosis. This should explain the medical necessity for performing the procedure(s). If the postoperative diagnosis does not support the procedure performed, be sure the patient’s chart contains documentation to justify the procedure.

Step 10. Review code options with the physician who performed the procedure if the case is unusual.

Step 11. Assign final code numbers for procedures verified in Steps 3 and 4 and any addendum the physician added to the original report.

Step 12. Properly sequence the codes listing first and the most significant procedure performed during the episode.

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