Wiki Medical Documentation

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NESmith

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What is the requirements for medical documentation to support the use of a surgical assistant in a procedure and where in writing can I get this information? Thank You
 
Teaching hospital?

You need to document the name/license of the assistant (MD, PA, NP, DO, etc), as well as that person's role as assistant.

Additionally, if you are in a teaching hospital, you much document the fact that no qualified resident/fellow was available to assist.

The assistant surgeon does NOT need to dictate a separate operative note. (Co-surgeons, however, must each dictate their own operative notes.)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Thank You ,but let me ask another question. Is it appropriate to dictate in the op-report as such; First Assistant--John Doe PA-C Surgical assistant is medically necessary and indicated due to the complexity of this surgery. Minimally invasive surgical technique requires 2 sets of trained hands for retraction, leg positioning and application of jigs. Is this enough documentation?
 
Surgical assists

If the payer usually does not pay for an assist for a particular code , but you have a complicated or unusual case, you will have to appeal the denial with documentaion stating why or what made the case complicated. (ie.. patient weigh of 350 lbs , required additional surgical hands to "blah, blah , blah"


kathy H.
 
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