By Erik Sunset, February 27, 2023 - 3 min read
Start here to get the basics for constitutes an operative report and the important sections that need to be included.
At its core, an operative report is simply the summary of a surgical procedure that becomes part of the patient’s medical record. Capturing the details of the surgical procedure, which is the surgeon’s responsibility, is an important aspect of documenting the procedure(s) performed and their medical necessity.
Additionally, the operative report, or op report for short, captures the details required to submit a claim to insurance that provides reimbursement to the surgeon, care team, and the facility.
The Operative Report Structure
Obviously, it’s not as simple for the surgeon as including whatever details they think are important. There is a structure to be followed for the generation of clean claims along with important time-based requirements as indicated by the Joint Commission.
What's in an Operative Report?
The required sections in an operative report are the Heading, History and Indications for Surgery, the Body, and Findings & Follow Up which we'll look at in detail below.
Op reports start first with a Heading. The Heading section includes information about the facility, patient demographics, date of service, name(s) of the surgeon(s) and anesthesiologist(s), pre and post operative diagnoses, and procedure performed among other data points.
History and Indications for Surgery
Next in the operative report’s structure is the History and Indications for Surgery. This section details why the surgery was necessary and any actions performed in advance of the surgery, as applicable. Here is where the surgeon describes how the illness or injury occurred, when it occurred, and it should also include any pertinent patient medical history, family history, and prior procedures.
The Body of the operative report is the most important and is where the surgical narrative is documented. The procedure needs to be described in detail from preparation to the very end including closures/dressings. A pro-tip for surgeons that will keep your billing team happy is to provide a description of whether the procedure was performed bilaterally or unilaterally and on which side.
Other important information to include in the Body are the approach, implants/devices used, use of robotics or other surgical assistance, specimens collected, intraoperative monitoring, and any portions performed by another surgeon.
The AAPC rightly points out that, in a billing sense, if something wasn’t documented it wasn’t done and may not be included in the billing. So, complete documentation is important to capture the full amount for reimbursement or you risk a denial or, unfortunately, a recoup after the documentation for the procedure is audited.
Findings & Follow Up
Finally, in the Findings & Follow Up section, the surgeon must provide a summary of the procedure, note any complications that arose, and provide guidance for follow up or future procedures.
The operative report is nowhere near as important as the actual surgical procedure and delivering an excellent outcome for the patient but it is close. As previously mentioned, a complete op report secures reimbursement for the surgeon and becomes part of the patient’s medical record.
The status quo for the completion of an op report is to create a voice file that is then worked up by a transcription company. Unfortunately, this builds an inherent delay into the surgeon’s and facility’s revenue cycle.
This speed bump can be completely eliminated, though, through the use of our Op Note solution. Learn more about Op Note here.