Procedure Note Integrity and Surgical CDI

Why is procedure note integrity a differentiator? We study procedure techniques. This gives us a conversational understanding of surgical nomenclature without the need to use coding language. Our enhancements produce the highest level of code capture with minimal queries.

Surgical CDI and Procedure CDI are still developing concerns at most institutions. Most teams, be they adult or pediatric CDI specialists, have a hesitancy to educate surgeons for fear of "telling them how to do the operation." Procedure and surgical CDI is not about telling surgeons what to do. It is about working with them on how to express what they did in writing so that all downstream consumers can use it effectively. This skill, in both the adult and pediatric CDI world, is highly specialized and takes a working knowledge of surgical technique. SMRT Doc consultants have been bridging the gap between common surgical nomenclature and ICD-10-PCS coding language for over 3 years. Let us help your adult or pediatric CDI program move into the world of surgical and suite based procedures making your reach truly 360 degrees.

  • -|  PCS and CPT Note Completeness Review - Review your highest volume and highest reimbursement procedures for note completeness and variability. We offer clinician-friendly language suggestions and clarifying statements to help coders understand and code the procedure with greater ease.

  • -|  Operative Report Template Creation - We work with surgeons to create explicit and compliant templates for repetitive surgeries leaving certain patient specific elements to justify case uniqueness. We outline formal reconciliation, assignment, query / clarification, response and compliance procedures establishing the new department with a workflow and metrics.

  • -|  Outpatient Procedure Note Template Creation - Create compliant and unique procedure notes customized by division for suite-based and in-office procedures that often go un-captured by hospital revenue.

  • -|  Medical Necessity Defense Enhancements - Insert customized and effective medical necessity clauses into the procedure notes and operative reports themselves making payor/RAC audits and record requests simpler with a higher justification rate.