Many of you liked my last post, “How I Personally Read an Inpatient Record,” so I think you might like this one too: how I personally read an op report. This method will save you time, especially if you are taking the coding exam. Every minute counts. Here is my order.
Step 1. Start with the preop and postop diagnosis.
The condition predicts the procedure. Cholecystitis points to cholecystectomy. A bunion points to bunionectomy. Carpal tunnel syndrome points to carpal tunnel release. Before I read the body, I know what to expect.
Step 2. Read the procedure title to confirm your belief.
If the title matches the story the diagnoses told me, I move forward with confidence. If not, that mismatch is my red flag to slow down.
Step 3. Skip the beginning and go straight to the incision.
The opening paragraph is positioning, anesthesia, prep, and draping. Most of the time none of that changes my CPT code. The exception: if the CPT descriptor mentions anesthesia, such as “under general anesthesia,” I go back and read that portion because it becomes a required element for code selection. Otherwise I start at the incision, which tells me the approach and where they enter: skin, tendon, ligament, bone, or body cavity. The approach drives the code family.
Step 4. Find out what was done and how.
What was removed, repaired, released, or destroyed, and by what method: excision, ablation, repair, decompression. The method plus the site is the CPT descriptor in narrative form. Match the surgeon’s words to the descriptor and the code selects itself.
Step 5. Look for extra work outside the ordinary.
Surgeons do not always list everything in the header, but they describe it in the body. During an open bowel resection, the surgeon may find a suspicious mass nearby and perform a needle biopsy. That biopsy is separately reportable and never appears in the title. Code from the header only and you leave revenue on the table.
Step 6. Read the closure to confirm the approach.
Some procedures can be performed either open or endoscopically, and sometimes the title fails to state which. The closure is my clue. Open ends with a layered closure: fascia, subcutaneous tissue, then skin. Laparoscopic ends with small port site closures, often a single layer or skin adhesive. If the closure does not match the approach I assumed, I check for conversion language.
Step 7. Respect the pathology rule.
If anything was sent to pathology, I do not finalize the diagnosis yet. Any procedure waiting on a path report waits for the path report. The final diagnosis is coded from the pathologic findings.
That is my system: diagnoses first, title to confirm, straight to the incision, find the work, hunt for extras, verify with the closure, and let pathology have the final word.
I wish you all success on your coding journey.
Hoang Nguyen, BS, CCS, CCS-P, CIRCC, CCVTC