The operative note as billing documentation: a preliminary report.

Certified professional coders from a multispecialty academic surgical practice used operative notes to identify 10 of the most common deficiencies for reimbursement of services. These 10 deficiencies were then used as evaluation criteria to audit the operative notes used as billing documentation. Twenty-four per cent of operative notes contained no deficiencies, whereas the remaining 76 per cent contained one or more audit criteria deficiencies. The three most common deficiencies identified included an incomplete description of all surgical procedures performed (56%), an inadequate description of the indications for procedures (49%), and only 45 per cent of the operative notes were dictated within 24 hours of the procedure. Thirty-nine per cent were dictated by faculty surgeons, whereas 61 per cent were dictated by surgical residents. Twenty-nine per cent of the operative notes that were dictated by faculty surgeons contained no deficiencies as compared with 20 per cent of the operative notes that were dictated by surgical residents. For a multispecialty academic surgical practice, the operative note is the document of justification for 75 per cent of revenue generated. We conclude that 1) the operative note represents the most important document for justification of reimbursement for surgical services, 2) surgeons should reassess the operative note as a billing document and provide the information necessary to expedite reimbursement, 3) surgical residents should be instructed in the details of an operative report as a billing document, and 4) most of the information needed in the operative note for billing purposes is simple and straightforward data that is important not only for reimbursement but also from a medico-legal and medical records standpoint.