Surgical documentation question posed recently

[Guest guest]

Listserv,

recently someone posted a question about a surgeon's need to document for a gallbladder-ectomy. The post seemed to indicate that surgeons probably didn't need to document as much as we are asked to. I can't remember the post source as I type, but I decided to speak with a close friend (anesthesiologist) and ask about her chart noting requirements. She is in an OBGYN surgical unit and has 25 yrs experience in her field. Her first sentence refers to her not knowing what we have to submit and that when she has worked with Kaiser, there are different more stringent requirements. The 3rd sentence and all the rest of her statement, refers to more general case charting requirements.

This post is just meant to show another profession's requirements since we've been on the topic. If others have colleagues/friends in different medical fields, and they care to comment for our benefit on this issue, it might be interesting to see.

Minga Guerrero DC

I am not sure exactly what is submitted with the initial claim to insurance. Kaiser is self contained so it is different.

I know that if there is a question that insurance can request the chart for review.

The review individual is usually an RN called a " case manager ". This person reviews the record and using criteria determines if the case meets criteria.

They would expect to see an initial note and assessment of chief complaint. History and physical exam documentation, Patient subjective complaints, providers objective evaluation of the situation, any testing done ( x-ray, lab, etc ) that support the diagnosis, and treatment instituted such as conservative management then progressive treatment applied. Also any consultations that took place.

Each diagnosis has a different set of criteria. The criteria are based on clinical outcome criteria, standard of care, textbook support of presenting symptoms and so on.

If the diagnosis is not properly documented and supported by OBJECTIVE data the claim is likely to be denied. The insurance companies LOVE to deny claims. The best defense against denial of a claim is impeccable documentation that stands up to scrutiny.

Kay