Surgical Procedure Documentation

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Surgical ProcedureDocumentation

• Presented by
• Alan Tipton CPC, CPC-H
• Institutional Compliance Program

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Surgery

• A form of medicine dealing with manual and
  operative procedures for the correction of
  deformities and defects, repair of injuries and
  diagnosis and cure of certain diseases.

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• Documentation of surgical procedures may be
• __________________________________
• or
• __________________________________

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Types of Surgery

• Major
• Minor
• Endoscopic

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Elements of a surgical note_____________________
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Elements of a surgical note_____________________
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Elements of a surgical note_____________________
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Resources for coding surgical procedure
notes __________________________________________
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Rules to keep in mind when coding surgical
notes __________________________________________
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