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How a surgical technology solution can improve physicians' notes, workflow and billing — 3 takeaways

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The complexity of medical coding makes accurate and streamlined surgical documentation critical; if the notes lack necessary detail, the billing and reimbursements may be wrong, ultimately costing the provider money.

During a Nuance-sponsored, virtual session as part of Becker's 18th Annual Spine, Orthopedic and Pain Management-drive ASC + The Future of Spine Conference in June, two surgeons discussed how solutions like Nuance Surgical Computer-Assisted Physician Documentation can help providers create accurate operation notes. The panelists were:

  • Lucian Newman III, MD, general surgeon and CMIO, Nuance Communications
  • William Haller, MD, orthopedic surgeon and member of the advisory board, Gadsden (Ala.) Regional Medical Center 

Three takeaways:

1. Incomplete or missing operation notes put an estimated 2 percent of revenue at risk. Surgeons are responsible for operation notes, capturing patient-specific procedure and recovery information, and the details necessary for billing and reimbursement. Unfortunately, while trained in their respective disciplines, doctors are often not well versed in medical coding, which can lead to delayed billing and incorrect payments. "All of our financial reward is tied up in the complexity of accurate documentation," Dr. Newman said of the traditionally freeform and error-prone documentation process.

2. Structured, guided documentation improves overall note quality. Using a software-based solution like Nuance SCAPD streamlines the documentation workflow, improving accuracy. The software-as-a-service solution poses questions to the physician, assigning the correct medical codes based on the responses. For example, the surgeon is prompted for specifics, whether a cyst that was operated on was superficial or deep, or whether a fracture needed manipulation. While the answers ultimately drive billing codes, to have accurate coding, the physician only needs to know the details of the procedure, not the specific codes.

3. Streamlined surgical documentation workflows improve overall efficiency. Not only does the structured workflow impact the bottom line by ensuring proper billing and payment, but it improves overall efficiency. The guided approach allows physicians to develop their notes faster, adding in photographs and other essential information to help with postoperative or future care. For example, Dr. Haller said he writes his notes immediately after surgery as his physician's assistant completes the wound closure. This increases accuracy, as the procedure is fresh in his mind, decreasing his postoperative workload. "It has made my post-case workload simpler, easier and shorter," Dr. Haller said. He added, "For me, the biggest win is I have no work to do when I'm done for the day."

To learn more about the event, click here.

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