Practice tip of the week: Boosting reimbursement

With all the useful information available on Physicians Practice, it is easy to become overwhelmed.

With this in mind, the tip of the week is a chance to reflect on some of the wisdom found all across the site. In this July 2021 on boosting reimbursement through improved documentation Dorothy Steed, RN gives this tip:

Give procedure specifics

Surgical notes should clearly identify the approach, all procedures performed at the surgical encounter, and any unusual situations that happened during the operative session. For instance, multiple spinal injections necessitate that the provider identify whether the injections are bilateral in the same level or in several levels. Or, if a procedure is stated as “complicated,” the provider should be specific about how the determination was made.

For example, lesion measurements should be stated, and make sure to specify both when the measurement was taken and whether the measurement includes the margins. If the coder is left to rely on the pathology report for information on lesion size, the measurement will not be as accurate as it would be if taken and documented before the tissue was removed from the blood supply.

Click here to read the rest of the article and be sure to check back next week for another Tip of the Week!