A Guide to Surgical Clinical Documentation

Tips by Tiensa Lundien

When it comes to documentation for insurance billing, every detail matters. Clinical documentation stands as a foundation for effective communication between healthcare providers, coders, insurance companies, and ultimately, patient care. As someone with 20+ years of plastic surgery billing experience, I've witnessed firsthand the pivotal role that meticulous documentation plays in ensuring accurate coding, billing, and comprehensive patient treatment plans. Here are some of the biggest things to keep in mind when creating documentation for insurance billing:

Cut the Fluff:
Lengthy, longwinded notes may seem thorough, but they often obscure crucial information amidst unnecessary details. When documenting patient encounters, keep it brief, aim for clarity and conciseness.. Avoid tangents or irrelevant observations that only serve to clutter the record.

Consolidate Procedure Discussions:
Efficiency is key when documenting procedures. When multiple procedures are being performed in the same operative session, ensure that all discussions pertaining to a specific procedure are consolidated and presented together in the note when possible.. By organizing information cohesively, you facilitate accurate coding and decrease the chance of denial due to lack of documentation.

Specify Procedure Locations:
Ambiguity has no place in clinical documentation, especially when it comes to anatomical locations and measurements. For instance, simply mentioning a "scar revision" leaves room for interpretation when multiple procedures are being performed on different body parts. Specify the precise location of the procedure including laterality when appropriate. Clear documentation eliminates confusion for coders and ensures that insurance companies have a comprehensive understanding of the services rendered.

Include Measurements:
Measurements are invaluable in many medical specialties, especially surgical specialties. When applicable, incorporate measurements into your notes in a clear and accessible manner. Dependent on the procedure being performed, be sure to document the required dimensions and provide the total measurement for accurate coding. If the same procedure is being performed multiple times on the same anatomical site and requires consolidation for coding be sure to list each measurement separately and then notate the total measurement for proper coding.  

Detailed Bilateral Procedures:
When performing bilateral procedures, consistency and specificity are crucial. Avoid the pitfall of providing detailed information for one side and resorting to generic statements like "same procedure" for the other side. Treat each side individually in your documentation, detailing the procedure performed and its location. This approach ensures comprehensive documentation and facilitates accurate coding for bilateral procedures.

Unbundling Incidental Procedures:
Some procedures may be considered incidental, yet their unbundling may make sense if the work required goes outside the typical scope of the bundled procedure. When documenting such procedures, it's imperative to provide clear justification for why unbundling is warranted. Whether it's due to the complexity of the case, the necessity of additional resources, or other relevant factors, thorough documentation ensures transparency and compliance with billing regulations.

Contractual Understanding:
Understanding the nuances of contractual agreements is indispensable for healthcare providers and billing professionals alike. Each payer may have specific requirements regarding billing for certain procedures, modifiers, or documentation standards. It's crucial for practitioners to familiarize themselves with the terms outlined in their contracts to avoid billing discrepancies and potential claim denials.

Effective clinical documentation is not merely a bureaucratic requirement to waste time; it helps make sure you’re painting a clear picture of what your plan of action is and helps you justify what you’re billing to insurances.

PS² can create customized consulting packages to work one-on-one with practices to improve their documentation processes.

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