Document minor surgery

Don’t take shortcuts just because it’s “minor.”

Your patient needs a procedure. The doctor states he can do it today and tells you to please set up the instruments. Your next steps help to ensure a happy patient and an accurate medical record.

Here are the answers to the crucial questions regarding the documentation of “minor” surgery.

How do I know it qualifies as a “minor” surgery or procedure?

In this case, no matter what you, the doctor, or the patient think, the decision lies with the payer. A general guideline is: If the surgery you are planning has a zero- or 10-day post-operative period, it’s minor. If it has 90 post-operative days, then it is a “major” surgery.

What you suspect is usually correct in terms of major vs minor, but surprises exist. For example, YAG laser treatment is not always major. The laser peripheral iridotomy (CPT 66761) is minor, with a 10-day post-operative period but YAG capsulotomy (CPT 66821) is major with 90-day post-operative period. Another example: Focal laser photocoagulation (CPT 67210) is a major procedure but panretinal photocoagulation (CPT 67228) is minor, according to nearly all payers including Medicare. Be sure to check.

What do you need to document?

You need to know what the doctor wants to do and whether there will be special preparation. The chart should clearly document the condition prompting the procedure (the “what”) and the medical indication for doing it (the “why”). Otherwise, you might not have the proper chart documentation to reach medical necessity, the most important first step to obtaining coverage.

Is the service covered?

Next, investigate insurance coverage to ascertain who is responsible for payment. Remember, not all insurances cover the same things — or even have the same covered diagnosis list. For example, not all skin lesions are covered. If a patient wants you to remove something because it “looks bad,” it might not have coverage. Also, consider that minor procedures might have surprising costs so, it’s important to know who is responsible for the costs at this time. If it’s not covered, and the patient is responsible, execute a financial waiver so it’s documented that the patient agrees to be financially responsible.

What else should be included in the medical record?

Consent. This should be documented in the chart. Protocol may vary from a formal, written document, to an informal patient consent to the procedure. Written consent is not required for some procedures, such as lash removal by forceps.

An operative report. This demonstrates what happened. The complexity varies from minor to major procedures, but in either situation it should contain the following (if applicable to the procedure):

  • Preoperative and postoperative diagnoses
  • Indications for surgery
  • Full description of the procedure(s), which includes, if applicable:
    • Which eyes or lids are involved. Include the size of any lesions and the size of the hole after removal (the repair size sometimes determines which code applies) and whether something is sent to pathology and how sent (in formalin, other)
    • Any devices used during the procedure, with lot number and expiration date (e.g., punctal plugs or amniotic membrane)
    • Drugs used (lot number, name, concentration, expiration date) and route of administration (intravitreal, other)
    • For lasers, include wavelength(s) used, number, size and time (exposure) of spots or applications, specific area treated, laser lens used (e.g., Abraham or other), and any complications
  • Discharge instructions, including any drugs or other concerns (when to call back and for what reason, when next appointment is scheduled for)

Modifiers. The most commonly used modifiers with minor procedures: 24, 25 and possibly 78 or 79 are in play. This article isn’t designed to cover them, but prior OP coding articles have dealt with some of these ( , ).


Minor procedures have their own set of rules but are largely similar in documentation. Fully and properly document to support your claims and collect.

As always, “good coding to you.” OP