Practice Management Alert
Seeing Double: Know Your Documentation Obligation When Billing
Question: Is it true that in order to bill for a co-surgery, both physicians are required to dictate their own report (each separate from the other)?
Wyoming Subscriber
Answer: Each surgeon involved in the procedure should certainly document his/her activity during the surgery in the surgery report, according to M. Tray Dunaway, MD, FACS, CHCO, with Healthcare Value Inc. and Rebel Records Inc. in Camden, SC.
"If you are the surgeon, you should dictate the report," he notes. But there doesn't appear to be a need for "two dictated operative reports," Dunaway continues. The co-surgeon can simply "dictate his/her part in addition to the standard note dictated by the other surgeon," he says. That way, both surgeons are represented in one report.
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