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Tip: Avoid 'canned' op reports

Ambulatory Surgery Reimbursement Update, May 13, 2008

Advise surgeons to avoid the use of “canned” op reports. You know what these are; all the op reports for a particular type of surgery look exactly the same. Most often canned reports will show up for cataract, pain management, and sometimes gastro-intestinal procedures, but they can occur with any specialty.

Medicare and other payers frown on the use of “canned” op reports to document procedures. They can also be an issue for both the ASC’s and physician’s malpractice insurance carrier—such as when complications aren’t documented in the rare instance when they do occur.

If the physician performs similar procedures and wishes to use some sort of template, he or she must tailor it adequately to each patient’s individual surgery and circumstances for use, and it shouldn’t appear to be “canned.”

This tip is brought to you by Ellis Medical Consulting, Inc.

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