Surgical Oncology Coding

Abstract

Just as there are increasing complexities to procedures performed for oncologic purposes, there also are increasing complexities to the coding. And as surgeons, beyond the medical record, we are in charge of the source document—the operative note. It is imperative to document thoroughly and completely and refrain from generalities in the operative note. It also is important to use certain terms in the ever more granular world of coding and documentation to ensure accuracy. Terms such as “through a separate site” or “bilateral” are necessary to define that more than one procedure was performed in that setting. Ensuring that not only the actions are described in the operative note but also the thought process behind straying from the typical scenario or planned operation should be included in the body of the document. These notations can justify why a part was or wasn’t performed for purposes of billing for that procedure.