2. To code an operative report the coder should first read through the entire report and take notes any possible diagnoses or abnormalities noted and any procedures performed. The coder should then review the physician’s list of diagnoses and procedures to see if they match. If the coder should locate a potential diagnosis or procedure not listed by the physician, they should bring this to the physician’s attention to see if it is significant enough to code. If preoperative and postoperative diagnoses are different, the coder should use the postoperative diagnosis. The coder should also review the pathology report if specimens were sent to pathology, to verify the diagnosis.... [continues]
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