Why is documentation so important for proper reimbursement for surgical procedures?
In order to get properly reimbursed for a surgical procedure, you must be able to prove through documentation what you’re are trying to get reimbursedfor. If you can’t prove it, then you will not get paid for it. Government programs such as Medicare and Medicaid have reinforced this policy in the past year, and have notified the healthcare industry that claims submitted where the documentation doesn’t support the charge will be denied.
This makes complete sense. If you are requesting payment for a procedure, then you should be able to prove what you did equates to the payment amount. However, this can be challenging for surgical areas. This requires surgical staff accurately documenting the procedure (i.e. what was used, changes in a procedure, etc.). This also requires surgeons taking the necessary time to accurately document what they did for a procedure. The procedure notes and physician notes need to support one another.
Why is it challenging for surgical staff to accurately document a surgical procedure? In Part 1 of this article, we discussed the distractions that can occur in a surgical environment. As we all can generally accept, people are human and humans can make mistakes. This can be compounded when there are too many distractions. If a patient becomes critical during a procedure, then (as you can imagine) this would take someone’s focus from documenting to being more attentive to the patient.
Why is it challenging for surgeons to document a procedure? In a perfect world a surgeon should document the procedure immediately after, but that isn’t the way it typically happens. Our surgeons are very gifted individuals, and because they are gifted their time is usually in high demand. Sometimes they get pulled into other procedures to advise or they need to start their own procedure shortly after the prior one. These activities add up and the documentation gets pushed to later in the day, or week, or even month. Remembering the details of a specific procedure after performing more procedures is the challenge for surgeons.
How can supply usage and technology help surgical staff and surgeons with better documentation? If a hospital had technology that provided a hands-free solution to capturing and documenting what supplies were used in a procedure, then that technology could help surgical staff and surgeons in the following ways.
For surgical staff, they currently need to manually document supply usage during a case, but what if they didn’t have to? Having the supply usage electronically sent over to the procedure documentation system would save surgical staff time, mental resources of having to remember, and eliminate any human error component in documenting what items were used.
For surgeons, imagine if you had a report with a chronological list of supplies that you used in a procedure. This usage report would serve as a road map to help recall the details of the procedure. An interventional radiologist commented, “Sometimes I use so many devices, I can’t remember what I used and the sequence.” This roadmap report provides insights for surgeons that help them recall the details of the procedure. In addition this same IR doctor commented that it increased the speed for doing documentation because it enabled to copy/paste information from the report into the surgeon’s notes for the procedure.
In Part 1 we said, “We get paid the same amount for a DRG isn’t entirely true.” A DRG is meant to be a mechanism for quantifying the cost for performing a certain type of procedure. In some ways, a DRG equates to the average cost for performing a procedure. That being said there are exceptions in procedures where it takes more surgical resources to perform a certain type of procedure due to the patient requiring more care. Thus, there are 3 variations of every DRG to accurately reflect how much surgical resources were needed for a given patient procedure. Each variation has a different average cost associated to it. The more care needed then the more money a hospital can receive for reimbursement for a procedure. The key to driving higher reimbursements is accurate documentation. If a surgeon has access to road-map information that can help to recall the details of the case, then this can help improve documentation that can drive higher reimbursements.
Part 1 & 3 of this article can be found here: