tci General Surgery Coding Alert - 2000 Issue 4

Findings Section in Your Op Report Can Make Billing Easier

General surgeons should include a short section in their op notes that explains what they found, what they did and why they did it, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs executive committee. Although physicians have very good reasons for performing certain procedures, that information may not be as obvious to others, Eisenberg says, noting that office staff, carriers and other doctors all benefit if the op note contains a Findings section. Physicians make a lot of intuitive decisions that others may not follow. A findings section would help othersyour own...

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