Jan 6, 2020 · The operative report is perhaps the single most important document in a surgical chart. It is the official document that captures what transpired in the operating room. It must support the …

Nov 1, 2024 · Key points in the medical record lead to proper code selection. Incision and drainage (I&D) is a common surgical procedure used to treat infections Key points in the medical record lead …

Jun 1, 2023 · Are inaccuracies in patients’ medical records costing your practice? Accurate documentation of time in the medical record serves two purposes: to ensure Are inaccuracies in …

Apr 1, 2025 · When two surgeons perform distinct parts of a procedure, both acting as primary surgeons for their part of the service, they will both document an operative note to reflect the services they …

Oct 17, 2016 · California Subscriber Answer: Yes, there are specific steps that the op note must document for you to appropriately code an Endoscopic Mucosal Resection (EMR) procedure. When …

Nov 1, 2024 · Documentation and Coding Challenges Debridement documentation needs to be descriptive enough to create a clear picture of the procedure performed. It is a level of detail that can …

Mar 1, 2024 · Understanding the global period and modifiers used for cataract surgery will keep your coding error-free. While cataract surgery is a commonly performed Understanding the global period …

Feb 3, 2025 · The more clearly you can visualize a procedure, the more easily you can translate it into organized, actionable codes. To take this a step further, consider shadowing a surgeon during actual …

Jun 15, 2015 · A surgeon’s operative notes should stand alone to provide all the necessary documentation to describe the procedure (s) performed. Every operative note should include:

Sep 5, 2024 · If a qualified resident isn’t available in a teaching facility, which means the assistant surgeon has to perform the entire procedure, then the physician must document the unavailability in …