Wiki Surgical Documentation Guidelines


New Iberia, LA
Best answers
Can someone please lead me to a link or a site where I can find the Surgical (Operative Report) Documentation Guidelines. I work for an Ambulatory Surgery Center and my doctors think they do NOT have to follow any type of rules. We go round and round about this every day, but I need some written proof to be able to back up my nagging.

PLEASE ANYONE HELP!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
what kind of guidelines are you looking for exactly. Your physicians surely know they must document procedure reports or they cannot be billed. So I am kind of fuzzy on what you are wanting.

:eek:My doctors know this too, but they are think they are above the guidelines. I am looking for something that would tell them, in writing, about documentation. For example I have one that uses meniscus pathology as a diagnosis and when I query him he gets upset as to why I am asking such questions. I am looking for something that would tell him that he has to dictate EXACTLY what he wants like the actual diagnosis of meniscus tear.
This is getting so frustrating.

Every conference we all go to they tell us that the doctors must document, document, document, but I need that is writing to put in their hands to prove what I am saying.

I am not sure what to say! I can give you this from the coding guidelines as a start:
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
Thanks, I just wish someone had what they teach US in writing so we could have it to show OTHERS, especially the doctors. We have this much trouble now just think what it will be like when ICD-10 comes around.
The statment I gave you can be given to them in writing from an official source:
Just read the first page. The statement above is on the first page along with the statement:
Adherence to these guidelines when assigning ICD-9-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA).
You have such an uphill battle, hang in there!
Trust me I know, I send out a query and they send me back snide remarks, so my administrator is sending out a memo to direct all of that to him and not to me. Hopefully that will help some. I just take it so personally.

Thanks for the info. I am going to get it now.:)

If your facility is accredited, that accrediting organization may have record content guidelines. Additionally, state licensure boards (in some states) spell out the appropriate documentation levels for providers (e.g., minimal requirements), but tend to be more vague than an accrediting agency. What I'm thinking of here is Joint Commission or one of the several others.

Especially for Radiology, the professional association (ACR) has documentation "standards". This sometimes holds true for other specialties, but I have rarely used any others.

Lastly, since the administrator is involved, recommend a revision or establishment of medical staff by-laws. They probably exist and give providers specific privileges and guidance on how to carry out their duties. For most organizations there is a medical record policy embedded in these and leveraging those documentation expectations appropriately will help the providers understand their expectations and hopefully improve documentation quality and detail.

This is perhaps the biggest challenge we face. It can be so difficult to select the appropriate code with a high level of comfort over that code selection when you have ambiguous or misleading health record entries. I hope some of what I've offered helps. Documentation Improvement is sort of the newest catch phrase for facilities trying to ramp up their record quality level. Unfortunately, it is sometimes the last thing some providers want to participate in...

Good luck.