American Health Information Management Association (AHIMA) Certification Practice Exam

What does the operative report provide in terms of coding?

1. Diagnosis validation

2. Detail of surgical technique

3. Size of excised lesions

4. List of pre-operative medication

The correct answer is: Size of excised lesions

The operative report primarily serves to document the surgical procedure performed, which includes a variety of critical details necessary for accurate coding. One of these details is the size of excised lesions, as this information is essential for determining the appropriate codes for procedures involving surgical excision. Accurate coding relies on precise measurements, and the size of excised lesions can influence the selection of CPT (Current Procedural Terminology) codes, as different sizes may correspond to different codes reflecting the complexity or extent of the procedure. In contrast, while diagnosis validation is crucial, it is usually established from the patient's medical record and not specifically a function of the operative report. Similarly, while details of the surgical technique are vital for understanding how the operation was performed, those details do not necessarily translate to coding for diagnosis or procedures in the same way that size does. Lastly, the list of pre-operative medications pertains more to patient management prior to surgery and does not provide direct coding implications for the surgery itself. Thus, the emphasis on the size of excised lesions highlights its significance in coding accuracy and procedure identification in surgical contexts.