tci Part B Insider - 2011 Issue 12

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.A reader contacted the Insider and said that her surgical practice waits for typewritten operative reports before billing...

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