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Topic: Urge physicians to note necessary details to ensure proper coding

Ambulatory Surgery Reimbursement Update, June 24, 2008

Complete coding demands complete physician documentation. Physicians must document all the necessary details so that ASCs can bill for primary procedures, as well as any other secondary procedures that a surgeon performs. However, physicians often omit these critical facts from their documentation. When coders have to engage in a back-and-forth query process with physicians to obtain the information they need, reimbursement delays result. To improve coding accuracy and timely reimbursement, you must consistently communicate to physicians specific ways that they can improve their documentation.

Post these five tips in your ASC to remind physicians of critical elements to include in their documentation: 

  • Not documented, not done
  • Document procedures in the body of the operative note, not just the heading
  • Document the surgical approach that was taken in the procedure
  • You can never document too much information
  • Always document the preoperative size for lesion removals

Lesion size is a common omission from documentation, says Sandy Berreth, RN, BS, MS, CASC, chair of the Minnesota Association of ASCs and administrator at Brainerd Lakes Surgery Center in Baxter, MN.

Differences in tumor sizes can also make a significant difference in terms of coding and reimbursement. “The majority of physicians don’t work from a template for their documentation, and they all have their own method of dictation,” she says. “That’s one of the biggest problems with physician documentation. Physicians become very accustomed to the sameness of their notes.”

“Also, if the physician removes a significant lesion, you can bill for the lesion and the complex closure. Now you’ve added another procedure you’re allowed to bill with proper documentation and Medicare will pay for both; the complex closure as the primary and the lesion removal as a secondary procedure, depending on the edits,” says Berreth.

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