ASC Documentation Mistakes, How to Avoid Them and How to Properly Document Modifiers

How often have you heard this phrase, "If it wasn't documented, it wasn't done?" The first concept I convey to physicians is that each specific medical record is unique in its own way and must withstand legal questioning. The medical record is used to create an infrastructure that supplies the necessary personnel with imperative information to deliver the best patient care. Legible and accurate documentation within the patient's medical record is an essential step in supplying vital information. Communication between physicians is also driven by the patient's medical record. Without readable documentation, the patient's health can be in jeopardy. The physician has an opportunity to increase revenue through educational sessions regarding "best practice documentation."

The physician is not the only personnel within a practice responsible for the documentation. All clinical and non-clinical staff having a reasonable purpose and necessary motive in the patient's medical record must adhere to documentation guidelines, whether it is for an evaluation and management visit or for an operative report. This article will concentrate on ASC procedures, with a focus on compliancy within an operative report including preoperative and postoperative visits.

Preoperative information
Documentation on a medical record should begin when the office personnel contacts the patient to discuss the preoperative session. At this time, he or she should request that the patient (or in some circumstances, a family member) bring proper identification and all the medications he or she currently is taking to the office visit. In so doing, the possibility for incorrect information (whether a drug name or dosage amount) can be minimized. The patient should be asked if he or she knows what type of surgery he or she is coming in for, including what side of the body the procedure will be performed on and why the surgery is needed. This information must be documented within the patient's record.

The medical record must have documentation from a history and physical that has been performed already, by the patient's primary care physician. The physical must have been performed and documented within 30 days of the procedure or service and updated the day of the procedure to confirm the information has stayed the same. Confirmation or any alternative information taken at this time should be documented properly within the patient's record.

Operative note
The operative report must be dictated directly following surgery and processed within 24 hours. The reason for an operative report is to document the steps involved prior, during and after the service or procedure — otherwise known as preoperative, intraoperative and postoperative sessions. No matter the specialty, you must ensure that the following documentation is included within each surgical note:

• Preoperative and postoperative diagnosis
• Title of procedure
• Surgeon, co-surgeon and/or assistant surgeon
• Anesthetic and anesthesiologist
• Summary of procedure
• Complications and unusual services
• Immediate postoperative condition
• Estimate of blood loss and replacement
• Fluids given and invasive tubes, drains and catheters used
• Hardware or foreign bodies intentionally left in the operative site

"I don't have time to dictate all this information." "Why does it matter who else was present? I am the primary surgeon!" "You want me to document complications!" I have heard it all before. What physicians must understand is that definitive documentation is a crucial part of their responsibility. The medical report is not complete if the above bullets are not addressed. Full disclosure is always recommended and does not necessarily have to accompany an admission of error.

The preoperative and postoperative diagnoses are needed to establish medical necessity and crosswalk with the appropriate CPT codes. A coder will use the postoperative diagnosis, which should unveil the definitive diagnosis. If a postoperative diagnosis is not given, the coder must attempt to obtain the preoperative diagnosis or obtain one through the body of the operative report.

First, the coder will read the entire operative report to understand what services the physician performed. Next, he or she will abstract the appropriate codes along with any necessary modifiers to accompany those codes and supply them to a third-party payor to receive maximum reimbursement. If the physician has not supplied the coder with the necessary documentation within the body of the operative report, the coder will be unable to support the code selection, and restitution for the physician will not be equivalent to the skilled time and services rendered.

The following are a few examples of cases where necessary documentation has not been provided:

• If two or more quadrants are resected, but the physician's documentation is vague, a coder must assume only one quadrant has been resected and can only code for a partial procedure instead of a complete procedure. The physician must make use of descriptive detail to be definitive with his or her documentation.
• The same is true if a procedure is extensive, complete and bilateral or bluntly dissected. Ambiguous documentation will point to a lower service.
• A simple closure is part of the surgical package and cannot be billed separately. If a closure exceeds the description for a simple closure (superficial or subcutaneous level) and it is not documented, the coder will be unable to bill separately, eliminating the opportunity for reimbursement to be set at a higher level. "Layered closures," "deeper layers of subcutaneous tissue," "superficial fascia," "scar revision," "stents" and "extensive" are all key words and phrases that need to be documented to indicate that a closure is more intense than a simple closure.

The following sections demonstrate a few instances where reimbursement, as well as compliance, can be affected if the operative note is not complete.

Documenting modifiers

• -50 (Bilateral procedure) — Looking at the modifier description, the documentation must represent a procedure that has been performed during the same operative session by the same physician on both sides of the body. Coders must use this modifier only on unilateral codes.
• -52 (Reduced services) — At the physician's discretion a service or procedure is partially reduced or eliminated. Documentation must state why the service was reduced, what was performed and what materials were used up until the decision to reduce the service was reached — all while ensuring that the identification of the basic service was not disturbed.
• -58 (Staged or related procedure or service by the same physician during the postoperative period) — This modifier may be used when a procedure is planned prospectively at the time of the original procedure. Documentation must state that the procedure was: a) planned or anticipated, b) more extensive than the original procedure or c) therapy following a surgical procedure.
• -59 (Distinct procedural service) — Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion or separate injury not ordinarily encountered or performed on the same day by the same physician.
• -73 (Discontinued outpatient hospital/ASC procedure prior to the administration of anesthesia) — Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure prior to the administration of anesthesia. Documentation must state the reason for the termination, the services that actually were performed, the supplies that were provided and the actual time spent in each unit of the surgical procedure, including pre- and post-op care.
• -74 (Discontinued outpatient hospital/ASC procedure after the administration of anesthesia) — The same documentation guidelines apply as for modifier -73, except the termination exists after the administration of anesthesia.
• -76 (Repeat procedure or service by same physician) — Medical necessity must be stated to ensure the need to repeat the procedure. Documentation must state that the procedure was performed at different times, different intervals or for comparative purposes. Also, it can indicate that the intervention was used for follow-up treatment.
• -77 (Repeat procedure by another physician) — The same requirements apply as for modifier -76, with the condition that the physician not be the same physician that performed the original procedure.
• -78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) — The title indicates that the procedure performed was unplanned; therefore, the procedure was unforeseen. This modifier is used when complications originate from the initial procedure. Documentation must state the complication or, in most cases, emergent type of service warranting the return to the operating room.
• -79 (Unrelated procedure or service by the same physician during the postoperative period) — The documentation must show that the services rendered were unrelated to the original procedure which was performed by the same physician and is within the postoperative period. Documentation must state medical necessity and point to a different diagnosis. The services are not confined to surgical procedures, nor does it command a return to the operating room. This modifier also can be used when an identical procedure, such as cataract surgery, is performed on two different dates within the global period on different sides of the body.

Postoperative information

• Along with the usual postoperative information taken by the clinical staff, it is important to document any unforeseen complications related and unrelated to the procedure.

Internal relationships
A certified professional coder should be on staff at every ASC. It is nearly impossible to keep up with the ever-changing guidelines within our world of coding and compliance unless the coder is constantly continuing his or her education. If the center decides to take on a new specialty, the coder also should be educated in that specialty. Without the help of a CPC, the practice will have a very difficult time accomplishing a high, clean claim rate.

The CPC and the physician should have access and availability to each other. Communication between the coder and the physician will ensure that concerns or questions regarding documentation compliancy are met. Education sessions and internal audit reviews should be put in place every three to four months. The time allotted between personnel will afford them the opportunity to review and update staff on any pertinent information for your specific specialties.

Thank you to Ben Jolley of the American Academy of Professional Coders for arranging this article.