This page addresses follow-up questions and additional information pertinent to our webinar
Getting Through Your First Op Report Without Crying.

** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q:  Can a coder code a surgical encounter without an operative report?
A:  The coder should always wait for the operative report before coding the encounter to ensure accurate coding and billing. There are often unplanned events that occur during surgery or the surgery could have been discontinued or not completed in its entirety. It’s always best to wait for the operative report.

Q:  Are all layered skin closures coded as intermediate repair?
A:  No. The CPT guidelines give definitions for simple and intermediate repair. The definition of intermediate repair includes layered closure of one or more deeper subcutaneous tissue or non-muscle fascia. If a wound requires layered closure of the deep dermal layer and a second skin layer, it is coded as a simple repair.

Q:  What are some official sources for coding references?
A:  For ICD-10-CM, the ICD-10-CM Official Guidelines for Coding and Reporting and Coding Clinic for ICD-10-CM/PCS contain official coding guidance approved by the Cooperating Parties. The Cooperating Parties for ICD-10-CM consist of the American Hospital Association (AHA), The American Health Information Management Association (AHIMA), the Centers for Medicare and Medicaid Services (CMS), and the National Center for Health Statistics (NCHS). For CPT, official references include the CPT code book guidelines, CPT Assistant, and, for hospital reporting under the outpatient prospective payment system (OPPS), Coding Clinic for HCPCS, which is published by the American Hospital Association. All references from CMS, such as the National Correct Coding Initiative and program memoranda are also official coding advice.