tci Medicare Compliance & Reimbursement - 2011 Issue 7

Part B Mythbuster: Don't Confuse Facility's Documentation Rules With Surgeon's Report

Concentrate on your physician's thorough note rather than comparing with the facility, experts say. Myth: When your surgeon performs surgery in a hospital, you should coordinate your coding with the hospital's records.Reality: Although that rule is smart for surgeries performed in ambulatory surgical centers (ASCs), it isn't true for facility-based surgeries. When it comes to coding for your surgeon's work, stick to your physician's documentation as a guide regarding what to report, and don't stress about what the facility documents. One reader comments that her surgical practice waits for typewritten operative reports before billing for the doctor's role...

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