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Deciphering an Operative Report



Lynn Anderanin


Webinar US




12:00pm - 1:00pm



CEUs: 1


Can't attend? Register anyway and you'll receive a link to the recording by the next business day.

About this program

The operative report is the legal account of the procedure(s) performed in a medical surgery for documentation and compliance. It tells the story of what was done and supports the medical necessity of the treatment administered. While the information contained in an operative report may not be relative to all that utilize it, having a clear understanding of its contents, medical terminology, and identifying parts will allow billing and coding staff to efficiently use the operative report for the purposes of billing, coding, and compliance.

The operative report also is used by billing and coding staff to assign the appropriate diagnoses codes, CPT® codes, and modifiers. CPT code descriptions can be different by only one word, so it is critical that the operative report contains all the information needed to assign the code that describes the procedure most specifically. Attend this detailed session for expert instructor guidance.

Modifiers will also be discussed, as they are used to share distinct information that would otherwise not be documented on the claim form. They also describe relationships between other procedure codes and other surgical sessions for the patient. Because the operative report is a written document of what was performed for a surgery, it can also assist to not only clarify, but also to prove what procedure(s) were performed.

Participants will learn:

  • The components of the operative report
  • How to use the procedures performed as a guide
  • What documentation is needed for assistants at surgery
  • How to identify the important pieces in the procedure description
  • What to do when there is conflicting information documented
  • How to use the operative report as part of your appeal
  • Assignment of modifiers to highlight the exceptions
  • Requirements needed for addendums and signatures