Mastering the Art of a Perfect Operative Note

Mastering the Art of a Perfect Operative Note

Mastering operative notes is imperative. Clear and precise op notes are what save considerable time on the back-end and allow for increased accuracy during the billing and coding process.

In healthcare, the details always matter. There are few who understand this as well as medical coders, who rely on every last detail to ensure cases are coded accurately, billed properly, and paid quickly. What’s one of their most valuable sources for detail? The operative note—notation taken by the surgeon during a procedure to indicate precisely what was done, what was used, and what was ordered post-op.

These op notes not only facilitate the seamless transfer of care from the operating room to the recovery room, but they also communicate what happened in the operating room to the billing and coding department to ensure the center gets paid for all of their efforts during a surgery. 

Here are a few quick tips for perfecting op notes in your facility:

Be Detailed & Maintain Proper Format

Start with the basics—make sure every op note includes standard information such as:

  • Patient Name
  • Date
  • Surgeon Name
  • Assistant Surgeon/Co‐surgeon
  • Applicable Pre-operative Diagnostics
  • Post-operative Diagnosis
  • Procedure
  • Changes to Planned Procedure

Indicate what was planned for the procedure and detail any changes that were made. If a procedure was made more or less intensive, canceled midway through, or resulted in contradictory diagnosis with a need for further testing, include those specifics in the procedure line. Also, don’t forget to notate any complication that may come up during surgery. During the coding process, those should be coded as additional codes.

Literally, every step taken (or planned steps that are not taken) should be reflected in the final op note. Think about it as a full operative report of what took place in the operating room; no detail is too small. You may be tempted to write a short op note to save time, which is okay as long as all of your bases are covered so you can receive the full reimbursement you deserve.

Use Templates Appropriately

Countless facilities rely on templates for op notes, which is great; templates help ensure consistency and efficiency and provide prompts to gather all relevant details. But they’re not without inherent pitfalls.

The golden rule for template use is simply to update the language when necessary. Don’t assume the template is accurate for every procedure—avoid contradicting information by cross-referencing the template content with the surgeon’s notes and editing as necessary.

Remember, an op note is a legal document that can only be altered by a physician, so make every effort to ensure template operative reports are updated and augmented to accurately and consistently reflect the procedure as it was performed (not just as it was planned).

Be Timely

Op notes are legal documents that are submitted to billing and coding to assist the center in getting their full reimbursement for each procedure. The quicker and more accurately they can be completed, the sooner the center can start the reimbursement processes. 

Best practice suggests that op notes be completed immediately following surgery so all the information is recent and the notes are as complete as possible.

Be Consistent & Don’t Fear Repetition

If an operative note says something once, most coders will assume that what was said is correct. If the same point is reiterated multiple times and in the exact same manner, the coder will trust that it’s an absolute fact. So don’t ever fear repetition. In fact, aim for it.

By extension, consider that every op note is a story, so details need to be conveyed consistently and accurately for the story to make sense. Make certain that details are consistent with all other medical documentation and diagnoses because a single contradicting element will absolutely stall the coding process.

Check Your Work

Double check that you’ve been thorough with the information you have provided and that all the details needed for the medical coding process are reported. Also, be sure to avoid common coding mistakes.

Taking the time upfront to do a quick review of your operative report can save time and get a better reimbursement for your center.

Quick Note for Coders

When coding from operative notes, be sure to read the whole note carefully starting with the demographic information. This is a great time for checking that the patient information is correct and can kick off your abstracting process. The pre and post diagnoses provide general information for why the surgery was needed. Remember the pre and post diagnosis might not match. The exact diagnosis or additional diagnosis may be found during the surgery, so be sure to make a note in the op report. Dig into the body of the operative report to ensure you get all the detail necessary to assign the right medical codes.

The Long & Short of It

Taking a little extra time upfront to create clear and precise op notes can save considerable time on the back-end and allow for more accuracy during the billing and coding process. That means claims are processed quickly, patient collections are executed timely, and everyone (ideally) gets paid sooner.

Maybe you need a new pair of eyes to evaluate your op note templates. Or perhaps you’re wondering whether things could run more smoothly between your physicians, transcriptionists, and coders. Stop wondering. Contact us, and let in2itive Business Solutions evaluate your documentation processes and deliver the training and tips that could help you avoid hold-ups and denials. Be sure to ask about pairing our billing services with charge entry options to streamline and expedite your revenue cycle. 

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