Updated on: November 28, 2016

Dissecting the Operative Report in ICD-10: Ten Tips to Extract Key Information

Original story posted on: September 28, 2015

The operative report is truly a goldmine of information. This is true in ICD-9, and it will be even more important in ICD-10, when coders will need to look for more specific anatomical information, as well as additional details about the procedure itself. They’ll need to read each and every line looking for details related to the root operation, the surgical approach, the device, the body part/region, and more.

As in ICD-9, coders will not be able to rely on the procedure title. Rather, they must review the entire body of the report looking to answer certain key questions. Did the physician perform the procedure that he or she intended? Did the physician perform any additional procedures? Were there any complications? What about the specificity necessary to assign a complete ICD-10-PCS code? It may require some digging to find all the details essential for an accurate PCS code.

In this article, I’ll provide a step-by-step analysis of a de-identified operative report. Coders can apply this same process to any operative report they code. The key is to take one’s time to process the information. Think carefully when choosing the root operation and other code requirements, and avoid unnecessary queries.

ICD-10 Success Hospital
Operative Note

 Patient: Happy Coder

Age: 69   DOB: 10/1/45 Sex: Female

MR#: 10012015

Date of Procedure: 10/1/15

Surgeon:  Itwill B. Okay, MD

Resident Assistant: Ralph Root, MD

Anesthesiologist: Bob Pcs, MD

Anesthesia: General

Pre-op Diagnosis: Pressure ulcer of right buttock, stage 4

Post-op Diagnosis: Chronic osteomyelitis, pressure ulcer of right buttock, stage 4

Procedure: Excisional debridement of right ischial pressure ulcer with ostectomy, application of Integra

Complications: None

Specimen(s) to Pathology: Right ischium

EBL:  100cc

Findings: Wound size of 5.2 cm x 4.2 cm x 0.2 cm with soft bone indicative of chronic osteomyelitis. Completely debrided of nonviable tissue

Indications: 69-year-old patient with long-term pressure ulcer of the right buttock, stage 4. She has failed outpatient therapy with local wound care. CT demonstrates evidence of bone erosion. She presents for debridement and application of skin substitute. She suffers from CAD, hypertension, and Parkinson’s disease.

Description of Procedure: The planned procedure was reviewed with the patient along with risks, benefits, and alternatives. Consent was signed. The surgical site was marked with the participation of the patient. She agreed to proceed.

Patient was brought to the operating room and helped onto the operating table in the left lateral decubitus position. She was prepped and draped in the usual sterile fashion. General anesthesia was induced.

Attention was immediately directed at the right ischial wound. The entire wound bed was curetted, removing a thin layer of granulation tissue. Punctate bleeding was noted. The right ischium was just below the surface of the granulation tissue, with multiple areas of soft bone noted once further incisional access was obtained. This nonviable bone was excised with ronguer. Specimens were submitted for microbiology as well as pathology. Complete excisional debridement of nonviable bone was achieved. Nonviable skin edges were excised.

The wound was irrigated with 3 L of warm pulsatile jet lavage and hemostasis was achieved with Bovie electrocautery. A 2x2 inch piece of Integra was pie-crusted and the graft was affixed to the lower portion of the buttock wound for full thickness coverage. This was secured to the skin edges using 3-0 chromic interrupted and running sutures.

The patient was reversed from general anesthesia and brought to the post-anesthesia care unit in stable condition.

Step 1: Review demographic information. This includes patient name, age, medical record number, date of procedure, surgeon, resident assistant, anesthesiologist, and type of anesthesia. Is this information accurate, and did the physician reference the correct patient? Is any of this information necessary for abstracting purposes?

Step 2: Note the pre- and post-operative diagnoses. These are general statements regarding the reason for the surgery. Additional details regarding the patient’s diagnosis may be found in the body of the operative note. Keep in mind that the post-operative diagnosis could be different from the pre-operative one. For example, the post-operative diagnosis in the report shown above includes a second diagnosis of chronic osteomyelitis, which was found during the surgery. The diagnostic statement for the ulcer provides additional detail required for coding the type, location, laterality, and stage of the ulcer. However, this isn’t always the case, and those specifics often need to be extracted from the body of the operative report.

Step 3: Read the general statement of the procedure. Be prepared to review the report itself for more or even different information.

Step 4: Check for complications. If the surgeon notes any complications, these should be coded as additional codes.

Step 5: Note the pathology specimen. Identifying the type of tissue removed may provide additional detail regarding what the physician did during the procedure.

Step 6: Check the EBL. This information could indicate potentially significant blood loss, prompting you to review the record for a documented diagnosis such as acute blood loss anemia or to provide additional clinical indicator support for the patient’s treatment and/or diagnoses.

Step 7: Review the findings. Findings provide a quick synopsis of the operative detail.

Step 8: Note the indications. This information provides background of the patient’s diagnosis, and it may assist with providing additional specificity for ICD-10-CM code assignment. Other pertinent secondary diagnoses may be listed as well.

Step 9: Read the description of the procedure(s) carefully. In the operative report above, the following language correlates to details necessary for PCS code assignment: 

Excisional debridement of right ischial pressure ulcer with ostectomy

  • Nonviable bone was excised – indicates a root operation of excision
  • Incisional access was obtained – indicates an open surgical approach
  • Right ischial wound  and non-viable bone – indicates the body part and laterality

ICD-10-PCS code:  0QB20ZZ

Application of Integra 

  • Graft was affixed to the lower portion of the buttock wound – indicates a root operation of replacement
  • Secured to the skin edges – indicates an external approach
  • Integra was pie-crusted – indicates a skin substitute device
  • Lower portion of the buttock wound – indicates the body part
  • Full thickness coverage – indicates the qualifier

ICD-10-PCS code:  0HR8XK3

Step 10: Double-check your work. It never hurts to take a quick look back at the details of the report after you’ve chosen a code. Those extra few seconds could make a big difference in terms of accuracy.



Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Cathie Wilde, RHIA, CCS

Cathie Wilde, RHIA, CCS, is the director of coding services for MRA. Ms. Wilde has been active in the healthcare industry for more than 30 years. Her previous positions have included assistant director of HIM, DRG coordinator at the Massachusetts Hospital Association, and DRG validator at Blue Cross Blue Shield. She has extensive experience in ICD-9-CM and CPT coding, auditing, data analysis, development and testing of coding products, specialized reporting, and in-service training. As director she is responsible for overseeing the coding division, providing the strategic direction of MRA as a local industry leader of quality coding, auditing, and denial management services. Ms. Wilde is an American Health Information Management Association (AHIMA)-approved ICD-10-CM/PCS trainer.

Related Stories

  • Proposed Biannual ICD-10 Implementation Dates: Weighing the Pros & Cons 
    Understanding the impact on business processes in the event that biannual ICD-10-CM and PCS updates are implemented is essential – as is your feedback.  With a comprehensive agenda covered at the virtual ICD-10 Coordination and Maintenance Committee meeting earlier this…
  • CDC Releases Updated Guidelines
    The guidelines are effective from Jan. 1, 2021 through Sept. 30, 2021. On Dec. 16, 2020, the Centers for Disease Control and Prevention (CDC) released updated ICD-10-CM Official Coding and Reporting Guidelines for 2021. The updated document can be found…
  • ICD-10 Codes Amid the Pandemic and the U.S. Election
    The mood of the country impacts claims. There are a few words that can be associated with the pandemic and the election. These words are the following: Stress – a state of mental or emotional strain or tension resulting from…