Critical ASC Mistake: Failure to Regularly Audit Dictated Surgeons' Reports

Bill Gilbert, vice president of marketing, and Brice Voithofer, vice president of ASC and anesthesia services, for AdvantEdge Healthcare Solutions, discuss the dangers of not regularly auditing dictated surgeons' reports.

Bill Gilbert: As with all of the critical touch points of the billing process, it is critical to perform regular audits of surgeons' dictated reports. It's not uncommon when you audit the report to find that the surgeon missed mentioning one or two items. Missing a few items here or a few items there can not only have substantial revenue implications, but repeated errors in dictated reports also carry the potential for severe compliance exposure. The dictated report is critical to the success of the billing process. Given the importance of proper case documentation, it's pretty easy to see why periodic audits for accuracy are important.

Brice Voithofer: It's common to review and audit coding to identify and prevent future errors, but it's necessary to remember that dictated reports can also benefit from the same sort of review. There are a couple of ways to audit dictated surgeons' reports. One is to go into the system and look at the instrumentation that was used, the approach that was used, and any inconsistences (e.g., the nurse's notes mention something that doesn't match up with what the surgeon said.)

Second, where physicians use a handheld device or a telephone phone-in type of communication system, you can request a full day's worth of the taped messages and have them sent on a computerized audio file for review by a separate individual. It's like someone is repeating the process. Frequently, the nurse manager or OR manager listening will say, 'but this happened.'

Obviously you can't go too far back because no one will remember the specific case. That is why we recommend the audits occur within one week of the case, and involve each player in the case (surgeon, nurses, tech, etc.). With recent cases, there is a better chance someone will clearly remember what happened. Oftentimes, it's the surgeon not saying something on the report or a dictation company not understanding the nuances of what the surgeon might be saying. Another pitfall to avoid is assumptive dictation, where items are added to the dictation because, "the surgeon always does X, Y and Z when doing this procedure."

Following these steps to audit your surgeons' reports will reduce denied claims, increase compliance and ensure you are receiving compensation based on what actually occurred in the OR.

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Read more insight from the AdvantEdge Healthcare Solutions leadership team:

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- Costly ASC Mistake: Poor Upfront Collections Process

- 3 Common Surgery Center Billing, Coding and Collection Mistakes

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