How to Do Medical Coding from an OP Report

How to do medical coding from an op report? Any tips?

Okay so what I did is I went out and I just Googled sample op reports. I’ve had a lot of feedback after these webinars and quite a few of you commented how you really liked me showing how I look up things and figure things out. So I’m going to try and be conscious of that more and share with you how I found things so you could kind of be your own little detective here. I mean, ask my family. Anytime they have a question, I go, “Google it.” And my niece who’s 14, she visits me. She’ll ask me something, I’ll say, “Google it.” And I got her a smartphone but she… I know she has the ability to do it. She’s like, “That’s how I want to raise my kids. I’m just going to tell them to Google it.”

But here, I found a pdf example of an op report so there’s tons of them out there and you can use them to you know, practice coding. Obviously, you don’t have coding answers but I say that in this first one, I found actually did.

Okay, great. This is just right out there on Google. I just pulled it up. It’s designed to help transcriptionist understand how to layout op reports and how to format them and things like them. So this is typically what you would see in an op report you know, the patient’s name, all the identifiers, date, etcetera. For coders, these are the 3 lines that are really what we want to can on initially. So from a procedure standpoint, you jump right to the procedure line, bilateral, upper lid blepharoplasty. They actually spelled it and you will not find this on the exam of course so they give you the suggested CPT code. But basically, this is what you start with. And there’s all of this long, long, long op report. And yes, you should read it but always start with the procedure. Look up the code or codes and you’ll probably find several and you want to look at the difference you know, between those codes and in this case, it said bilateral. But if it didn’t say bilateral and it just said blepharoplasty and there’s several codes for upper lid, lower lid, you would have to go abstract that information from the body of the report. But start with the code to see what information you need to take the correct code.

And this is a great question because for those that haven’t taken the board exam yet, that’s how you really should attack surgery questions is you want to look the answers first. Don’t read the whole op report. You don’t have time or just not have enough time you know, there’s 5 hours and 40 minutes for 150 questions. You can’t read the op report then go look up the code and then end up reading the op report again. You need to know the differences between the answers you know what to pull out from the report. Are you looking for unilateral versus bilateral? Are you looking for upper versus lower? Okay so that’s how I attack an op report.

And then of course, you do the same with the diagnoses. What you’re coding for is a post-operative diagnosis. And you want to be careful sometimes because sometimes, the pre-operative diagnosis just sounds the same as the post-operative but you want a code whatever they say that the post-operative one is. In this case, it happens to be the same thing.

So that is how I would attack an op report.

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