What are the different report used in Surgery Coding ?

1.Operative Report (Procedure description and medical necessity)

2.Pathology Report (Path finding of Specimen )

3.Anethesia Report (Anesthesia type and duration)

4.H&P (For additional diagnosis and indication of procedure)

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1.Operative Report

This is the most important document for surgery coding.
It includes:

• Pre-op diagnosis

• Post-op diagnosis

• Procedure(s) performed

• Detailed description of the surgery

• Findings

• Specimens removed

• Complications

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2.Pathology report

Used when tissue, tumors, or specimens were removed.
Helps confirm:

• Diagnosis

• Malignancy vs benign

• Margins

Important for ICD-10 diagnosis clarity.

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3.Anethesia Record

Useful for:

• ASA physical status

• Anesthesia type (general, regional, MAC)

• Start and end time

• Modifiers for anesthesia services

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4.History and Physical

Used to understand:

• Patient condition

• Medical necessity

• Comorbidities

• Reason for surgery

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5.Radiology

Examples:

• X-ray

• CT

• MRI

• Ultrasound

Useful for:

• Preoperative diagnosis

• Fracture type

• Torn ligaments/meniscus

• Localization of lesions

 

See Sample below

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