Optimizing Reimbursement: Improving the ASC Operative Report
Accurate coding requires an accurate operative report. Providers should dictate complete and timely reports, including the following information:
if the procedure took longer than normal;
if it was more difficult than normal;
complications encountered;
implants and high-ticket items used (full description);
all procedures performed;
lesion diameter excised and method used;
length of laceration repair and areas repaired;
for arthroscopies: each compartment entered, what was performed and time spent; and
for colonoscopies: each area of colon biopsied and technique used.
This information allows the coder to:
add modifiers to increase payment;
fully code all procedures while remaining compliant;
bill for implants and high-ticket items; and
request pathology reports for accurate procedural and diagnosis coding, when necessary.
Optimizing reimbursement starts with good communication between the provider and the coder.
