Getting Surgical Documentation Right

Coding Q&A
What vitreoretinal surgeons need to know about operative reports, medical necessity, and coding rules that impact reimbursement.

By: Elizabeth Cifers, MBA, MSW, CHC, CPC

Retinal Physician July 1, 2026 Vol 23, Issue July-August 2026 Page(s): 31

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Operative reports must document the indication for surgery, diagnoses, surgical findings, and any deviations from the planned procedure.
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Specific details in operative reports, such as the exact locations of retinal tears, enhance the documentation's support for the work performed.
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Medical records should document the necessity for surgery, including signs, symptoms, alternative management options, and discussions with the patient.
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Mismatches between diagnosis and procedure codes are a frequent cause of claim denials, necessitating careful documentation.
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Modifiers 78, 58, and 79 are used to indicate the relationship of subsequent procedures to the original surgery during the global postoperative period.

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