Hello there!
Finally have time to get a little more in depth with the quality of all of our documentation. I am curious if anyone has any good resources to confirm CMS requirements for the components of an op report, specifically for colonoscopies. At this time we are watching out for the obvious (sedation, consent) as well as withdrawal time, scope used, bowel preparation score (typically boston). I'm wondering if there is anything we are missing along the way. I am also wondering if it is required to give an actual number for the bowel preparation score or if saying that the bowel prep was "adequate" or something along those lines is enough? We have one or two providers who tend to leave off scores and give an impression instead. Any advice is appreciated