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How ASCs can improve documentation accuracy to protect revenue

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Incomplete and inaccurate documentation can hinder appropriate and timely reimbursement, placing an ASC's financial stability at risk. 

Two percent of an ASC's surgical revenue is at risk without accurate documentation, explained Lucian Newman, MD, Chief Medical Information Officer of Nuance Healthcare, in a featured session at Becker's Orthopedic, Spine, and ASC Virtual Event.

In the March 18 session, Dr. Newman was joined by Michael Damrich, Account Executive for the Community Hospital Market at Nuance Healthcare, to discuss how artificial intelligence-powered solutions can solve documentation issues without disrupting a surgeon's workflow to drive reimbursement and protect a practice's bottom line.

Here are four key takeaways from the session, which Nuance Healthcare sponsored:

1. EMR or dictation app templates can lead to documentation issues. Many EMR or dictation app documentation templates lack prompts and the level of detail necessary to help surgeons capture accurate documentation and the right CPT code, Dr. Newman said. 

2. Small details in documentation make a big difference. ASCs may be leaving money on the table by omitting details such as the severity level for standard procedures, Dr. Newman said. For example, there are three severity levels when doing an excision of a pilonidal cyst: complicated, extensive, and straightforward. A surgeon who did not know about the levels may code for the simple procedure, a 2.66 relative value unit. In comparison, a complicated pilonidal cyst excision is a 7.35 relative value unit. "The amount of money we're talking about when you multiply this by the number of cases you do can be significant," Dr. Newman said. 

3. AI-powered solutions can solve documentation issues. Nuance's Surgical Computer-Assisted Physician Documentation (CAPD) helps ASCs improve surgical note completeness, accuracy, and billing without disrupting a surgeon's workflow, Mr. Damrich said. 

4. It's important to understand what physicians are not documenting. Unlike typical EMR templates, Nuance's Surgical CAPD solution gives insights into how physicians document, what physicians are documenting, and most importantly, what physicians are not documenting, Mr. Damrich said. This can help facilities find ways to improve documentation. "This is the only tool out there that can give you that level of visibility into what's not being documented," Mr. Damrich said. 

To learn more about Nuance's Surgical CAPD solution and walk through a demonstration on how it works, view the event on-demand here

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