Certified Coding Specialist (CCS) Practice Exam 2026 – Comprehensive All-in-One Guide to Achieve Exam Success!

The operative report is essential for accurately capturing the complexity and specifics of a surgical procedure because it documents the details of the surgery performed, including the reasons for the procedure, the techniques used, and any complications encountered. This report serves as the primary source of information for coders to designate the appropriate codes that reflect the specific actions taken during surgery.

The operative report typically includes specific sections like the preoperative diagnosis, postoperative diagnosis, findings, technique, and any special circumstances, which are crucial for coding accurately. A thorough operative report provides comprehensive insight into what occurred during the procedure, allowing coders to select the most precise codes available.

Although other documents, such as the history and physical examination, the patient's discharge summary, and consultation notes, contain valuable information about the patient's condition and treatment, they do not provide the level of detail specific to the surgical intervention needed for precise coding. These other documents might offer context or background information but lack the specifics required to properly evaluate the complexity of the surgery and establish accurate coding.