Practice Management: Distinguish Facility's Documentation Rules From Surgeon's Report

Article Overview

This practice management article reviews the separate documentation expectations that apply to hospital facilities and surgeons during facility-based surgery. It discusses general compliance concepts, the role of The Joint Commission, and the importance of relying on the physician’s operative documentation when determining the professional service to report. The article is relevant for coders, compliance staff, and physician practice managers who work with surgical records and want to understand how facility documentation differs from the surgeon’s chart.