4 tips to improve ASC physician documentation

Physician documentation accuracy can be the deciding factor in whether an ASC is paid promptly and correctly.

Even small errors can lead to denials, payment delays, and possibly non-payments for services rendered.

Follow these four recommendations to help improve the accuracy of your physicians' documentation.

  1. Encourage detail. Remind your physicians that they should include as much detail as possible in their dictations. ICD-10 greatly expanded the set of diagnosis codes when it replaced ICD-9. This expansion in the quantity of codes brought with it an expansion in detail. The more detail physicians include in their dictations, the more likely it is that coders will code to the highest-level permitted, thus better ensuring your ASC receives the highest appropriate reimbursement.
  2. Emphasize implant dictation accuracy. Physicians are required to dictate the use of implants but are not required to dictate the count of hardware implanted or other details. For billing purposes, staff can refer to the implant log and invoices for this information. 

However, many physicians still choose to include implant details (e.g., screw count) in their dictation. This can become problematic when physicians dictate the incorrect hardware used. When the dictation does not match the log and invoice — for example, a surgeon dictating that a plate and two screws were used for the case when the log states four screws were implanted — physicians will need to complete an addendum to their dictation to ensure documentation is consistent. Failure to do so could lead to problems for an ASC if the documentation is later audited and the discrepancy is flagged.

  1. Highlight the value of timely response to queries. Business office staff — often coders — will occasionally require clarification from and questions answered by physicians to help get correct claims out the door. The longer physicians take to respond to these queries, the longer it will take for claims submissions. 

If physicians take lengthy periods of time to respond to staff queries, remind them of the effects to the ASC's — and possibly their — bottom line. Delayed claims lead to delayed payments. For an ASC on a tight budget, such delays can create challenges with covering expenses and making critical purchases. For an ASC performing well, delayed claims can mean lower distribution checks.

  1. Be prepared for mid-procedure changes. While most procedures in an ASC proceed as planned, sometimes a discovery made by a surgeon in the midst of a procedure will warrant a change in the surgery performed. This can create potential challenges for an ASC. 

One challenge is whether the code assigned to the new procedure performed is payable under the ASC's contract. If you come across a diagnosis that is not covered, send all the medical records back to coding to assess whether another code can be issued that would support medical necessity. If no such code exists, provide the physician with all the documentation associated with the case. Explain what verbiage is required to demonstrate necessity so the physician can dictate an addendum, if applicable.

The other challenge concerns authorization. Since the procedure code changed when the procedure changed, the new code was likely not authorized prior to the procedure. In cases like this, it’s important to know payer regulations. For example, one national payer requires any authorization changes to be completed within 14 days from date of service. If not completed during this window, the claim will be denied for lack of authorization. Some payers will require an appeal while others will permit updating of the authorization with the new CPT code over the phone.

For some procedures, it's best to secure authorization for a "range of codes" because these procedures are commonly associated with code(s) changes. Colonoscopies and esophagogastroduodenoscopies (EGD) are two such examples. These procedures are often scheduled as diagnostic but can become a surgical procedure based on findings (e.g., polyps). 

Another example is knee or shoulder arthroscopy. It is not unusual to see such cases scheduled as a meniscal repair, but then a meniscectomy is performed instead when the surgeon determines mid-procedure that the tissue cannot be repaired.

Angela Mattioda (amattioda@surgicalnotes.com) is vice president of revenue cycle management services for Surgical Notes. Surgical Notes is a nationwide provider of revenue cycle solutions, including, transcription, coding, revenue cycle management (RCM), and document management applications for the ASC and surgical hospital markets. Mattioda oversees the SNBilling RCM service, the fastest-growing component of Surgical Notes' complete end-to-end revenue cycle solution offering.

Copyright © 2023 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Patient Safety Tools & Resources Database

Featured Webinars

Featured Whitepapers

Featured Podcast