Differentiate Facility's Documentation Rules From Surgeon's Report

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You should concentrate on your physician's thorough note.


Here's a myth: When your surgeon carries out surgery in a hospital, you should make it a point to coordinate your coding with the hospital's records.


Reality check: Even though that rule is smart for surgeries carried out in ambulatory surgical centers (ASCs), it is not true for facility-based surgeries. When it comes to coding for your surgeon's work, remain glued to your to your physician's documentation as a guide regarding what to report, and do not stress about what the facility documents.


A lowdown: The facility is governed by a different set of rules than the office-based surgical coder.


Facility regs: The Joint Commission wants an immediate post-op note written after the surgery. The facility can bill from this as they are billing a different ‘type' of service. They're billing for essentially the room, the staff, the equipment, and the like. In fact, you can get the Joint Commission's documentation rules right here: http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=215&StandardsFAQChapterId=13.
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What constitutes immediate: As per the Joint Commission, the operative report must be written or dictated "immediately after an operative or other high risk procedure," and defines "immediately after surgery" as "upon completion of surgery, prior to the patient is transferred to the next level of care."


Physician regs: The surgeon's chart will cover detailed documentation based on the specifics of the surgery that she carried out and documented. It must be thorough and contain all the required elements about equipment count, sedation, pre- and post-op diagnoses, indications, description of the procedure, attestations, signature, and the like. The coder can then assign a proper service code to the description the doctor provides.


Bottom line: You should choose the proper code from the surgeon's documentation instead of waiting to coordinate with the hospital. If the notes are not thorough, take it up with the physician directly.


For more on this and for other specialty-specific articles to assist your general surgery coding, sign up for a good medical coding resource like Coding Institute.