Jove
Visualize
Contact Us
JoVE
x logofacebook logolinkedin logoyoutube logo
ABOUT JoVE
OverviewLeadershipBlogJoVE Help Center
AUTHORS
Publishing ProcessEditorial BoardScope & PoliciesPeer ReviewFAQSubmit
LIBRARIANS
TestimonialsSubscriptionsAccessResourcesLibrary Advisory BoardFAQ
RESEARCH
JoVE JournalMethods CollectionsJoVE Encyclopedia of ExperimentsArchive
EDUCATION
JoVE CoreJoVE BusinessJoVE Science EducationJoVE Lab ManualFaculty Resource CenterFaculty Site
Terms & Conditions of Use
Privacy Policy
Policies

Related Experiment Videos

The operative note as billing documentation: a preliminary report.

Michael B Flynn1, Dora A Allen

  • 1Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky 40292, USA.

The American Surgeon
|July 29, 2004
PubMed
Summary

Operative notes frequently have deficiencies impacting surgical reimbursement. Improving documentation, especially by surgical residents, is crucial for accurate billing and medico-legal compliance.

Related Concept Videos

You might also read

Related Articles

Articles linked to this work by shared authors, journal, and citation graph.

Sort by
Same author

Operative failure rate and documentation of family history in young patients undergoing focused parathyroidectomy for primary hyperparathyroidism.

The American surgeon·2015
Same author

Outpatient parathyroid surgery: ten-year experience: is it safe?

The American surgeon·2015
Same author

Minimally invasive parathyroid surgery, the Norman 20% rule: is it valid?

The American surgeon·2011
Same author

Current status of surgical techniques for parathyroidectomy for untreated primary hyperparathyroidism: is the technology worth it?

The American surgeon·2010
Same author

Parathyroidectomy in the elderly population: does age really matter?

The Laryngoscope·2009
Same author

Surgical and calcium outcomes in 427 patients treated prospectively in an image-guided and intraoperative PTH (IOPTH) supplemented protocol for primary hyperparathyroidism: outcomes and opportunities.

The Laryngoscope·2009

Area of Science:

  • Healthcare Administration
  • Medical Documentation
  • Surgical Billing

Background:

  • Operative notes are critical for justifying surgical services and revenue.
  • Deficiencies in operative notes can hinder reimbursement processes.
  • Academic surgical practices rely heavily on accurate documentation.

Purpose of the Study:

  • To identify common deficiencies in operative notes used for medical billing.
  • To audit operative notes based on identified deficiency criteria.
  • To assess the impact of documentation quality on surgical reimbursement.

Main Methods:

  • Certified professional coders identified 10 common deficiencies in operative notes.
  • A multispecialty academic surgical practice's operative notes were audited.

Related Experiment Videos

  • Deficiencies were evaluated based on criteria including procedure description, indications, and dictation timeliness.

    • Main Results:

    • 76% of operative notes contained one or more deficiencies.
    • Most common issues: incomplete procedure descriptions (56%), inadequate indications (49%), and delayed dictation (55% >24 hours).
    • Faculty surgeons' notes had a higher deficiency-free rate (29%) than residents' (20%).

    Conclusions:

    • The operative note is paramount for justifying reimbursement of surgical services.
    • Surgeons and residents require enhanced training on operative reports as billing documents.
    • Improving operative note quality benefits reimbursement, medico-legal standing, and medical records.