# key or critical elements of a procedure, teaching physician documentation



## mjl903 (Sep 27, 2011)

I am a fairly new coder for a dermatology practice at a teaching hospital.  I am trying to help update their template that is currently being used for documentation.  The only area that I am having any conflict with is where the teaching physician checks off 
" _The critical elements of the procedure _____________ were performed in my presence_".  They always write in what the procedure is which I believe is incorrect, they need to actually list what was done.  Because no other coder ever questioned this before they are fighting me on changing this.  
The first thing I want to do is move the line to follow the word "elements" I think this will help to clarifiy what they write.  What do your doctors write in this area, so I can give them some examples?
There isn't a lot of space on the template to make a big list so what do you suggest I do if they run out of room.  
Does anyone have any suggestions of how to handle this situation? I need as much written support as I can find/receive to help to make this change.
I just want to protect them from any auditing issues that may arise.  
Thank you so much for your assistance!!


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## mjl903 (Dec 1, 2011)

*Key/Critical elements of a Procedure - teaching physician*

I really could use some advise for my situation.  Thank you!!


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## FTessaBartels (Dec 2, 2011)

*Our Compliance Office has blessed*

I can only tell you that our Compliance office has blessed the statement:

"I was scrubbed and present for the critical elements of the surgical procedure(s) described above."

Our Compliance officials have stated that since CMS doesn't define what the critical portions are, it is up to the physician, and whether s/he spells out what s/he means by "critical portion" is immaterial. 

Of course if the surgeon was present for the entire procedure the statement should so indicate. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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