tci General Surgery Coding Alert - 2000 Issue 3

Case Study: Clearly Written Op Note Allows Billing for More Procedures

"When a general surgery coder reads the top of a surgeons operative note that lists a left hemicolectomy, along with repairs of umbilical and incisional hernias, insertion of mesh and insertion of right subclavian IV, she knows both hernias normally are bundled into the hemicolectomy. But by reading the entire op note before filling out the HCFA 1500 claim form, she finds that each of the procedures is separately billable. In the following operative report, the coder finds a carefully documented description of the surgical procedures that allows her to bill for the incisional hernia and the insertion of...

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