Submit Proper Documentation for Surgical Services

Submit Proper Documentation for Surgical Services

The main reason Medicare denies claims is because there is insufficient documentation in the medical record. For all surgical services, make sure the medical record has these four elements:

  1. Correct date of service
  2. Reason for procedure
  3. Signed operative report
  4. Physician signature and/or signature log or attestation for an illegible signature

Showing medical necessity is only one piece of the puzzle, however.

A general statement signed by the ordering physician saying that conservative treatment measures were tried and failed, is not enough. You must provide supporting documentation for the services being billed.

Documentation Improvement Tip

The Certified Documentation Expert Outpatient (CDEO®) credential validates a documentation professional’s expertese in reviewing outpatient documentation for accuracy in the support of coding, quality measures, and clinical requirements. Learn more about the CDEO credential.

Renee Dustman

Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. She has more than 20 years experience in print production and content management, and has worked in a variety of capacities for several publications.
Renee Dustman

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Renee Dustman, BS, MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. She has more than 20 years experience in print production and content management, and has worked in a variety of capacities for several publications.

3 Responses to “Submit Proper Documentation for Surgical Services”

  1. Tammy says:

    What about the BODY of the Op Report. Details need to be included IE, if an incision was made, how deep was the incision, incision site. These things are often missed. Just listing the 4 elements is not enough.

  2. Sandra Egan says:

    Nurse Auditors in the Audit and Appeal portion of our Finance Department review the chart before it is sent out in response to the ADR request. If Medicare – the signature must be legible or a legible identifier (pre-printed name.) must appear on the page with the signature. The signature must be dated and timed. If electronic, there are Medicare electronic signature requirements as well. If anything is noted missing, we have proactively appended a physician signature attestation. Preventing the denial through a few extra steps makes the most sense.

  3. Cindy says:

    Can a preliminary operative report be coded and claim submitted for payment? Is there a guideline that specifies it should be a final op report?

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