By K-cee Cagle, CPC, CASCC, and Briauna Driggers

Operative documentation plays a crucial role in patient care, medical coding, and regulatory compliance. A well-structured operative note ensures accurate communication among healthcare professionals, supports billing and reimbursement processes, and meets the regulatory requirements set by the Centers for Medicare & Medicaid Services (CMS). This article outlines the key elements of a compliant operative report and highlights best practices to ensure thorough and precise documentation.

Operative Report Structure

A CMS-compliant operative note should include the following key components:

Name(s) of the primary surgeon/physician and assistants – Clearly identify all medical professionals involved in the procedure

Pre-operative diagnosis – The condition(s) leading to the need for surgery

Post-operative diagnosis – The final diagnosis following the procedure, which may differ from the pre-operative diagnosis based on surgical findings

Name of the procedure performed – A precise description of the operation conducted

Findings of the procedure – Key intraoperative observations that may influence further treatment or prognosis

Specimens removed – If applicable, a record of any tissue or fluid samples collected for pathology

Estimated blood loss – An approximation of intraoperative blood loss, which can impact post-operative care

Date and time of procedure – A chronological reference for documentation and coding accuracy

Indications for the procedure – The medical rationale justifying the intervention

Intra-operative complications – Any adverse events encountered during surgery

Full description of the procedure – A detailed narrative of the surgical steps performed

Details, Details, Details

Comprehensive details in the operative note are essential to ensure continuity of patient care, support compliant coding and billing, and reduce audit risks. The procedure description is particularly critical as coders rely on this section to extract procedure codes. This section may also influence the application of modifiers, such as Modifier 22 (Increased Procedural Services) for increased complexity or Modifier 52 (Reduced Services) for incomplete procedures.

A well-documented procedure description should include:

Induction of anesthesia – The method and agents used to initiate anesthesia

Patient positioning – The specific positioning of the patient to facilitate the surgical approach

Set-up and use of special equipment – Documentation of specialized surgical tools or technology

Specific brand name of any implants – If applicable, the make and model of implanted devices

Role of each surgeon and assistant(s) – Clarification of individual contributions to the procedure

Indications for Surgery

The indications for surgery section establishes the medical necessity of the procedure and provides important context for coding. This section may also justify the use of certain modifiers, such as:

Modifier 58 (Staged or Related Procedure) – If the patient requires a planned return to the OR

Modifier 78 (Unplanned Return to the OR) – If the patient requires an unexpected follow-up procedure related to the initial surgery

Modifier 79 (Unrelated Procedure) – If the patient undergoes a separate, unrelated procedure during the post-operative period

Clear documentation of prior surgeries, post-operative complications, and future planned interventions improve the accuracy of claims and reduce the need for coding queries, helping providers receive timely and correct reimbursement.

Signature Requirements

CMS mandates signature requirements for two primary reasons:

1. To fulfill legal and regulatory requirements outlined in statutes, national coverage determinations (NCDs), or local coverage determinations (LCDs)

2. To confirm the authenticity and legitimacy of the documentation

When a scribe assists in documentation, CMS does not require the scribe’s signature. However, the treating physician or non-physician practitioner (NPP) must sign the note confirming that the documentation accurately reflects the care provided.

Assistant at Surgery Documentation

If an assistant surgeon is present, their role must be explicitly documented to justify medical necessity. This includes:

Specific tasks performed – Detailed actions taken by the assistant

Medical necessity for their presence – The justification for needing an assistant

Resident unavailability (if applicable) – If a qualified resident physician is unavailable, it must be documented

Merely listing an assistant in the operative report or using collective language such as “we” or “us” does not suffice to prove medical necessity.

Comprehensive and precise operative documentation is vital for patient safety, compliant billing, and regulatory adherence. A detailed, CMS-compliant operative note ensures clear communication, reduces the risk of claim denials, and upholds the integrity of the medical record. By following these best practices, surgeons and medical professionals can enhance documentation quality while safeguarding both patient outcomes and reimbursement processes.

References:

Centers for Medicare & Medicaid Services (CMS). “Medicare Claims Processing Manual.” (October 2024). www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c01.pdf

American Medical Association (AMA). “Current Procedural Terminology (CPT) Professional Edition.” https://www.ama-assn.org/topics/cpt-codes (November 2023).

Office of Inspector General (OIG). “General Compliance Program Guidance.” https://oig.hhs.gov/compliance/general-compliance-program-guidance

American College of Surgeons (ACS). “Operative Notes and Medical Necessity Compliance.” https://www.facs.org/quality-programs/cancer-programs/cancer-surgery-standards-program/cssp-operative-standards-toolkit