Physicians often focus on the operative report because they are responsible for creating the documentation that supports the surgical procedure. However, the operative report is only one component of the surgical record; the medical necessity for the procedure must also be documented in the chart before surgery. The following are common questions and answers regarding surgical coding.
Q: What documentation should be included in the operative report?
A: Operative reports should include the indication for surgery, preoperative and postoperative diagnoses,a high-level description of the surgery (eg, vitrectomy), the surgical findings and steps performed, and any unexpected events or deviations from the planned procedure.
The details and specificity of the procedure are critical. For example, in a case involving multiple retinal tears, it is better to specify that tears at specific positions (eg, 9-o’clock, 11-o’clock, and 2-o’clock) were treated with laser rather than simply stating, “any retinal tears were lasered.” A more specific statement better supports the work performed.
Q: Are templates or checklists acceptable for the operative report?
A: Boilerplate templates that include the most common steps, techniques, and procedures are acceptable, provided they are edited to eliminate ambiguity and accurately reflect the surgery performed. Checklists can be difficult to defend during an audit because they often lack the narrative detail needed to support the services reported.
Q: What documentation should be included in the medical record?
A: The medical record should clearly describe the signs, symptoms, or disease process that indicated the procedure was needed. It is also important to document alternative management options, such as observation, as well as the risks, benefits, and other options discussed with the patient.
If the medical record does not “back up” the need for surgery, the claim may be denied if the payer asks to review it. A copy of the operative report should always be kept in the practice’s medical records.
Q: Do procedure and diagnosis codes have to match exactly what is on the claim?
A: The indication for surgery should reflect the diagnosis, sign, or symptom established by the physician before surgery. However, both the procedure and diagnosis may change based on findings discovered during the operation.
For example, a surgeon may perform surgery for a retinal detachment and subsequently find multiple retinal breaks that require laser treatment. Mismatches between diagnosis and procedure codes are a common cause of claim denials.
Q: How do you determine whether to use modifier 58, 78, or 79 if the surgical eye is already in a global postoperative period? What about the fellow eye?
A: At a high level, if a patient returns to the operating room during the global postoperative period for a procedure related to the original surgery, modifier 78 may be appropriate. In that situation, the global period does not restart and payment is generally limited to the intraoperative portion of the service.
Modifier 58 may be appropriate when the subsequent procedure is more extensive than the original surgery. In these cases, a new global period begins, and the procedure is paid at the full allowable amount.
Modifier 79 indicates that the procedure is unrelated to the original surgery. Procedures performed on the fellow eye typically require modifier 79 because they are unrelated to surgery performed on the first eye. Assuming the fellow eye is not already in a global postoperative period for another procedure, payment should be made in full. RP
