Medicare Compliance & Reimbursement

Concentrate on your physician's thorough note rather than comparing with the facility, experts say. Myth: When your surgeon performs surgery in a hospital, you should coordinate your coding with the hospital's records. Reality: Although that rule is smart for surgeries performed in ambulatory surgical centers (ASCs), it isn't true for facility-based surgeries. When it comes to coding for your surgeon's work, stick to your physician's documentation as a guide regarding what to report, and don't stress about what the facility documents. One reader comments that her surgical practice waits for typewritten operative reports before billing for the doctor's role in the surgery -- but the corresponding hospital-based coder told her they just use handwritten operative notes that are in the charts when they do not receive the dictated operative reports in time to bill the surgery. She asked whether CMS has documentation requirements that the notes must be in a specific [...]