Choosing the specific amputation procedure code from the surgeon’s operative note can be a challenge for coders. If there is not enough information to know where the amputation took place, the coder will query the surgeon. Documenting that a “below-the-knee amputation” took place does not provide sufficient information to choose the procedure code that describes the surgeon’s work.
Including verbiage such as “proximal,” “middle,” and “distal” is very helpful. These words apply when the long structures of the extremities are being detached. This includes even the very small, long structures of the fingers and toes. These structures are being divided into thirds. Anywhere in the proximal third is high, middle third is mid, and the distal third is low.
Bottom Line: using verbiage such as proximal, middle, distal, high, and low when documenting your operative note is very helpful and provides sufficient information to identify the specific procedure to bill to the payor.
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