Find comprehensive information on surgical procedure diagnosis, including healthcare documentation, clinical terminology, and medical coding. Learn about operative procedure coding, surgical procedure definitions, surgical documentation requirements, clinical documentation improvement for surgical cases, and healthcare data analytics for surgical procedures. Explore resources for medical coding guidelines related to surgical procedures and best practices for accurate surgical procedure documentation. This resource offers valuable insights for healthcare professionals, medical coders, and clinical documentation specialists seeking to improve the accuracy and efficiency of surgical procedure reporting.
Also known as
Surgical Procedures
Codes for surgical operations and procedures.
Nervous System Procedures
Covers operations on the nervous system structures.
Endoscopic Procedures
Includes endoscopic diagnostic and therapeutic procedures.
Other Surgical Procedures
Encompasses various other surgical interventions.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the procedure diagnostic?
Yes
Biopsy performed?
No
Procedure involve excision/destruction?
When to use each related code
Description |
---|
Surgical Procedures |
Postoperative Complications |
Intraoperative Complications |
Separate coding of procedures normally performed together, leading to overpayment. Medical coding, CDI, healthcare compliance.
Using unspecified diagnosis/procedure codes when more specific options exist, impacting reimbursement and data accuracy. Medical coding, surgical procedures, CDI.
Omitting necessary modifiers that provide additional information about the procedure, affecting payment and compliance. Healthcare compliance, surgical procedures, medical coding.
Patient presented for surgical procedure. Preoperative diagnosis confirmed as [Specific Surgical Procedure, e.g., Laparoscopic Cholecystectomy]. Indications for surgery include [Specific Indication(s), e.g., symptomatic cholelithiasis with recurrent biliary colic]. Patient's medical history includes [Pertinent Medical History, e.g., hypertension, type 2 diabetes mellitus]. Surgical risks and benefits were discussed with the patient, and informed consent was obtained. Preoperative laboratory results were reviewed and deemed within acceptable limits for the planned procedure. Anesthesia type administered was [Specific Anesthesia Type, e.g., general anesthesia]. The surgical procedure was performed as planned. Intraoperative findings included [Specific Intraoperative Findings, e.g., inflamed gallbladder with multiple stones]. There were no intraoperative complications. Postoperative course was unremarkable. The patient tolerated the procedure well and was transferred to the recovery area in stable condition. Postoperative orders include [Specific Postoperative Orders, e.g., pain management, diet as tolerated]. Discharge instructions provided, including wound care, medication instructions, and follow-up appointment scheduling. ICD-10 code(s): [Relevant ICD-10 Code(s), e.g., K80.10]. CPT code(s): [Relevant CPT Code(s), e.g., 47562]. Keywords: surgery, surgical procedure, operative report, postoperative care, preoperative evaluation, anesthesia, surgical complications, medical coding, medical billing, healthcare, clinical documentation, EHR, electronic health records.