Help!!!!!!

[slc112071]

I need some help settling a disagreement in my office.

I have a surgeon that periodically forgets to dictate his assistants on his operative reports. I have had them added to the op-notes through transcription before. Now transcription will not add them. They are requiring the physicians to dictate an addendum to their operative reports. The facility always has their intra-operative report and the assistants are documented in that. I am being told to not have an addendum dictated and to go off the intra-operative report.

My question in this, is that this is the facilities medical record, not the physicians. Can I use that as the physicians documentation?

[koatsj]

When my surgeons forget to list our NPP as an assist in surgery, I ask them to dictate an addendum to the operative report. This way, if the insurance company asks for a copy of the op report, the assistant name is on it. I don't have access to the intra-operative notes from the hospital. I have to base my coding on the operative report and if the assistant name is not on it, I need my surgeons to add it if indeed an assist was needed so I can bill it out correctly.

[FTessaBartels]

Exactly what koatsj said ...

Hope that helps.

F Tessa Bartels, CPC, CEMC