What is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures?

The operative report is considered the proper supportive documentation for reporting CPT and ICD codes for surgical procedures. This report provides a detailed account of the surgical procedure, including the specific techniques used, the findings during the surgery, and any complications that may have arisen.

The information contained in the operative report is essential as it directly correlates with the codes assigned for both the procedure itself and any associated diagnoses. Accurately reflecting what occurred during the surgery ensures that the coding is precise and can withstand scrutiny during audits or insurance reviews.

While other documents like the patient consent form, referral letter, and pre-operative checklist can provide valuable context, they do not contain the detailed procedural information necessary for coding the specific surgical intervention. These documents may support the overall patient care narrative but lack the specific clinical details needed for appropriate CPT and ICD coding.