The operative report is the legal account of the procedure(s) performed in a medical surgery for documentation and compliance. The operative report also is used by billing and coding staff to assign the appropriate diagnoses codes, CPT® codes, and modifiers. While the information contained in an operative report may not be relative to all that utilize it, having a clear understanding of its contents, and identifying the pieces, will allow billing and coding staff to efficiently use the operative report for the purposes of billing, coding, and compliance.
Anyone billing and coding surgical cases must understand the documentation for the procedures performed. This session will take a look at the pieces of the operative report for a full understanding of the information that it supplies.
Senior Director of Coding Education for Healthcare Information Services, a physicians revenue cycle management company. She is a former member of the American Academy of Professional Coders (AAPC) National Advisory Board, and has served on several other boards for the AAPC. She is also the founder of her local chapter of the AAPC. Her experience is primarily in the specialties of Orthopedics, Rheumatology, and Hematology/Oncology. She has been a speaker for many conferences, including the AAPC National Conferences and Workshops, Community Colleges, audio conferences, and Local Chapters. Lynn became a CPC in 1993, and a Certified Instructor in 2002, and a Certified Orthopedic Surgery Coder in 2009.