Wiki Blanks in operative notes

[Dani_k_83]

We have a provider who is using a hospital template and there will often be blanks within the body of the note. For instance, the header says procedure was performed on Right Elbow. But in the body of the note it will say _x_ elbow was prepped, incision into _x_ elbow.

We are asking that the template be corrected and we are getting push back that it has been this way for years and unless we are having claims denied it is not a problem. Our coding team feel that if the laterality mention in the body of the op note was removed, as long as laterality is listed in the header, we would be okay.

Can anyone provide publication that says that having blanks is not acceptable. I've looked but am not finding much and am starting to doubt myself. My compliance team has not been helpful.

Thank you!

 

[amyjph]

How can someone code it in the first place if the body of the operative report doesn't have the correct laterality or any laterality? The ICD-10 and modifiers cannot be confirmed with an operative report like this. Where was the incision? In your example, no one knows. Is it wrong side surgery? How does the coder know the correct side if the header says one thing but there is no other documentation of the laterality in the body? They should not be coded at all like that. This is not only a coding issue but a patient safety and medical/legal issue as well. Bring it to the risk manager and/or attorney if your compliance department won't help. Go to the Chief Compliance Officer. If you are coding for the surgeon, the hospital should have a problem with this as well. Do they have a CDI department or compliance department?

Is the report being coded before it is finalized by chance? I have seen that too where someone is pulling a draft too soon and it is not finalized yet. Then, the finalized one is complete.

https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/downloads/docmatters-recorddoc-resourceguide.pdf

https://www.kzanow.com/articles/op-note-documentation-tips-every-surgeon-can-use

https://www.aapc.com/blog/24305-slice-and-dice-your-op-report/

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/certmedrecdoc-factsheet-icn909160.pdf

"Insufficient Documentation Errors CERT reviewers determine claims have errors when the medical documentation submitted is insufficient to support Medicare payment for the services billed (that is, the reviewer couldn’t conclude some of the allowed services were actually provided, were provided at the level billed, or were medically necessary). Reviewers also place claims into this category when a specific documentation element that’s required as a condition of payment is missing, like a physician signature on an order, or a form that’s not entirely completed."

https://www.aapc.com/blog/49512-dissect-an-operative-report/

"It is vital to code from this section and not code just from the procedure listings in the Heading. The procedures listed in the Heading should only give the coder a checklist of what to look for in the body of the operative report. If the coder finds a procedure is omitted, missing bilateral documentation, or any other discrepancies between the heading and the body, the surgeon should be queried immediately for verification and possible correction."

https://www.ahima.org/media/lcchdcez/physician-coding-toolkit_axs.pdf

"Template defaults help to improve the efficiency of documentation, but if not used carefully, may put the user at risk for inaccurate documentation"

 

[MnTwins29]

I would think that you would be getting denials for unspecified codes, especially those of laterality. We get those kind of denials - or I should say we did, until we did a lot education and assistance from our CMO, who pretty much said to the providers correct these or else. Fortunately, haven't had to see what the "or else" was!