The operative note is the one document in an ASC that the clinical and business sides both depend on. Coders build the claim from it, and when a payer or surveyor comes asking questions, it’s generally one of the first documents they pull. When I work with centers on documentation, the op note is often where issues begin, whether that’s a note dictated days after the case or one missing the detail a coder needs to complete a claim or a payer needs to justify payment. Most of those problems trace back to how the note is created in the first place.
Understanding the payment and compliance exposure
CMS’s 2024 Comprehensive Error Rate Testing data puts the ASC improper payment rate at roughly 15%, which translates to a projected $656 million. Documentation problems accounted for nearly 93% of that total, and coding errors accounted for around 7% – about a third of the improper payments involved missing documentation.
Some of those claims were likely for care delivered exactly as billed, but without a record to back it up. Coders can only work with what the surgeon documented, and a note that lacks the specificity a payer’s coverage policy requires won’t survive an audit no matter how accurately it was coded. The stakes rise with case complexity. When a procedure involves implants, hardware, or multiple billable components, a note that omits one of them can leave significant revenue unbilled or put the entire claim at risk.
The note is also a compliance matter. The Conditions for Coverage require the ASC medical record to include the findings and techniques of the operation, so a missing or incomplete op note is a survey finding on its own.
The physician side of the same problem
Chart closure time tracks with physician well-being. In a JAMIA Open study of clinic physicians, those experiencing burnout took about twice as long to close their charts as their peers.
In a surgery center, the op note is often the last piece of the chart still open after the patient goes home, and every note put off until the end of the day stretches that timeline. A coding query a week later reopens the chart and asks the surgeon to reconstruct the procedure from memory, which takes time and can introduce errors.
Measure before you change anything
Most centers already track days to bill, but fewer track the documentation measures influencing it. Start with:
- Days to dictate, by surgeon; one day is the standard benchmark, and same day is better
- Coding query volume and response time, by surgeon and procedure
- Documentation-related denials, by payer, to pinpoint where notes fall short
From there, ask your coding team or billing company to monitor op notes on an ongoing basis and share what they find with surgeons, including the specific coverage or medical necessity requirement a note missed. Set up a correction workflow around each surgeon’s preferred channel, whether that’s a flag in a mobile app, an email, or a quick conversation between cases, so queries don’t linger.
Give each surgeon an option they’ll use
A JAMA Internal Medicine study of over 18,000 physicians found that those whose team members authored more than 40% of their notes cut their own documentation time by 21%. The study looked at clinic physicians, often working with scribes, but the same logic applies in the ASC: the less of the note a surgeon has to build alone, the faster it’s done. The right support depends on the surgeon and the procedure, and the centers I’ve seen with the fastest op note turnaround usually rely on some combination of these:
- Direct entry with structured templates for high-volume, low-variation procedures such as GI and ophthalmology. The surgeon completes the template on a mobile device in a few taps, and the note is ready for coding immediately.
- Professional transcription for complex, variable procedures like total joints and cardiology, where surgeons want to dictate at length. An experienced transcription team returns a finished note, typically within two days.
- AI-powered dictation for any case. The surgeon dictates on their phone right after the case, using a template or speaking freely, then edits and signs a completed note within minutes.
Fit matters because a physician who finds a method slow or awkward will likely put off using it, and the note ends up late no matter which tool the center chose. A multispecialty center may use all three, and a single surgeon may switch between them depending on the case. The goal is to shorten the time between the end of a case and a complete note in your coders’ hands, with fewer open notes waiting on surgeons.
Process, people and technology together
Poor op notes cost an ASC one way or another, whether in denied claims or in surgeons finishing notes long after their last case. Keeping that cost down takes a process that sets clear expectations for timing and detail, people who monitor notes and close the loop with surgeons, and technology that fits how each surgeon works. When those three work together, the op note gets done while the case is fresh and reaches your coders ready to bill. If you’re evaluating documentation options for your ASC, our team at SIS is happy to share what we’ve seen work across surgeons and their specialties.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
