clark.amy86
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Assistants at surgery (non-MD: NP, PA, or CNS)
Our physicians are lack luster in their documentation of their assistants during surgery, which is causing denials and delays in payment. I am aware of the compliance standards that requires their active role to be documented in the body of the operative report, in addition to their name in the heading and under indications list the need for an assistant.
They are wanting exact verbiage and/or examples of what needs to be there and there isn't much available online in that aspect. I honestly feel like it is up to the physicians to determine this because of the many different surgeries they perform, but HR believes it falls on the coders.
Does anyone have any guidance or an example of proper documentation for this?
Our physicians are lack luster in their documentation of their assistants during surgery, which is causing denials and delays in payment. I am aware of the compliance standards that requires their active role to be documented in the body of the operative report, in addition to their name in the heading and under indications list the need for an assistant.
They are wanting exact verbiage and/or examples of what needs to be there and there isn't much available online in that aspect. I honestly feel like it is up to the physicians to determine this because of the many different surgeries they perform, but HR believes it falls on the coders.
Does anyone have any guidance or an example of proper documentation for this?