ASC Dictation and Transcription: Importance of Full Disclosure

Accuracy and completeness of the operative note is essential for determining what you are going to be paid. Procedures performed which can often provide additional reimbursement are frequently not identified in the operative note, nor is mentioning implants and ancillary procedures provided. As is often said in healthcare, "If it's not documented, it never happened."

Areas needing additional attention for dictation typically include:

• Bilateral or multiple procedures
• Identification of surgical site (e.g., fingers, toes (needed for modifiers))
• Specific areas treated (e.g., medial or lateral compartment)
• Detailed implant information
• Ancillary procedures performed
• Deviation from normal (e.g., more time, complications)
• Postoperative pain management details

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