Auditing Surgical Operative Reports: Clinical Documentation and Compliance Challenges

Event Information
Product Format
Prerecorded Event
Conference Date
Thu, May 24, 2018
60 minutes
Product Description

Get Tips on Auditing Surgical Operative Reports

Learning how to audit surgical operative reports is essential to any surgical compliance program and to the financial health of any surgical group. Most surgical groups focus only on auditing evaluation and management services without realizing they are still at risk for negative audit findings from federal and commercial payer auditors – leading to paybacks that the practice was not prepared for. These paybacks can render a practice or group financially crippled and in a compliance quagmire. Along with the compliance benefits, regular surgical operative report auditing helps the billing and coding team identify areas of possible lost revenue due to lack of clinical documentation, improper coding, or both – allowing for training and increased revenue on future services.

Join this session with medical billing and coding expert Dreama Sloan-Kelly, MD, CCS, to learn how to audit surgical operative reports. Dreama will provide you tips on audit guidelines and how to approach the process. You will learn how to document audit results and present to the practice administration, and how to effectively communicate with the surgeon so they are able to put into practice the recommendations. You will also learn what common issues may be triggers for payer audits

With this session, you will be able to audit surgical operative reports and identify any possible compliance issues, as well as identify any possible lost revenue secondary to missed procedures or poor clinical documentation. You will learn communication skills for communicating the results of the audit to the surgeon and manage audit tools to make the process of auditing easier.

Session Highlights

This session will help you learn:

  • What federal and commercial payer auditors are looking for
  • How to look for key terms that support the CPT® and ICD-10 codes billed
  • How to communicate with the surgeon what clinical documentation is required to support the CPT® and ICD-10 codes billed to ensure everything is billed to the highest level of specificity
  • How to look for possible missed revenue by comparing the documentation and the CPT® codes billed—locate what codes could have possibly been billed based on what was documented by the surgeon in the operative report—and identify what clinical documentation would have been needed to bill for additional services
  • Guideline requirements for the surgical operative report
  • Understand the best approach for the audit process
  • Appropriately evaluate the procedure codes
  • Tips on auditing procedure codes

Session Agenda

  • Auditing surgical operative reports: Compliance
  • Major risk areas in a practice
  • Factors that can make you a target for an audit
  • Biggest errors
  • Approaching the audit process
  • The operative report
  • Preparing for your audit
  • How are the diagnosis codes evaluated?
  • Auditing the diagnosis codes
  • Evaluating the procedure codes
  • Auditing modifiers
  • Managing data

Who Should Attend

General surgery, otolaryngology, OB/Gyn, orthopedics, cardiothoracic surgery, cardiology, neurosurgery, dermatology, ophthalmology:

  • Practice managers
  • Office managers
  • Medical billers
  • Medical coders
  • MDs
  • DOs
  • NPs
  • PAs
  • Clinical documentation improvement specialists
  • MR auditors

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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About Our Speaker

Dreama Sloan-Kelly - Healthcare and Medical Billing Coding Expert

Dreama Sloan-Kelly, MD, CCS has over 14 years of experience in the medical field. A graduate of Wellesley College and Tufts University School of Medicine, she has a varied background including clinical, billing, and coding. Dr. Sloan-Kelly is President/CEO of Kelly, Sloan, and Associates, LLC and speaks at various seminars and webinars, imparting her knowledge in an upbeat, matter of fact, manner. Her goal is get the...   More Info
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