CODING Q&A Minor Surgery but Not Minor Documentation
May 1, 2023
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4 min
This content discusses the importance of thorough documentation in chart notes for minor surgical procedures to avoid payment denials. It highlights the distinction between minor and major surgery as defined by the Centers for Medicare and Medicaid Services and emphasizes the necessary elements for comprehensive operative reports. Additionally, it stresses the significance of informed consent and the potential implications of inadequate documentation on payment recovery for minor procedures.
1. Adequate chart notes are essential for minor surgical procedures to avoid payment denials. 2. The Centers for Medicare and Medicaid Services provide objective definitions for minor and major surgeries based on global surgery package periods. 3. Comprehensive elements for operative reports, including patient indications, measurements, and medication details, are crucial for supporting minor procedures. 4. Additional considerations for laser cases and the necessity of documenting informed consent and risks are emphasized. 5. Inadequate documentation may lead to payment recovery issues for minor procedures.
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