Certified professional coders from a multispecialty academic surgical practice used operative notes to identify 10 of the most common deficiencies for reimbursement of services. These 10 deficiencies were then used as evaluation criteria to audit the operative notes used as billing documentation. Twenty-four per cent of operative notes contained no deficiencies, whereas the remaining 76 per cent contained one or more audit criteria deficiencies. The three most common deficiencies identified included an incomplete description of all surgical procedures performed (56%), an inadequate description of the indications for procedures (49%), and only 45 per cent of the operative notes were dictated within 24 hours of the procedure. Thirty-nine per cent were dictated by faculty surgeons, whereas 61 per cent were dictated by surgical residents. Twenty-nine per cent of the operative notes that were dictated by faculty surgeons contained no deficiencies as compared with 20 per cent of the operative notes that were dictated by surgical residents. For a multispecialty academic surgical practice, the operative note is the document of justification for 75 per cent of revenue generated. We conclude that 1) the operative note represents the most important document for justification of reimbursement for surgical services, 2) surgeons should reassess the operative note as a billing document and provide the information necessary to expedite reimbursement, 3) surgical residents should be instructed in the details of an operative report as a billing document, and 4) most of the information needed in the operative note for billing purposes is simple and straightforward data that is important not only for reimbursement but also from a medico-legal and medical records standpoint.
THE OPERATIVE REPORT serves a variety of functions. Most fundamentally, it is a record of patient care activity and an important component of both hospital and office records. It may be an educational document for resident training and may be of some scientific value for research purposes. Medico-legally, the operative note is a major factor in litigation related to surgery. The operative note provides documentation for billing to insurance companies for reimbursement of surgical services provided.1,2 The extent to which the operative note represents justification for revenue varies with surgical specialities, from 90 per cent in general surgery and plastic surgery to 45 per cent to 50 per cent for otolaryngology and urology.
In our recent review of the surgical literature in Medline and on the Internet, there was surprisingly little data related to operative notes.1-10 This current report is to evaluate the use of operative notes as a billing document in a multispecialty academic surgical practice.
Materials and Methods
Certified professional coders from a multispecialty academic surgical practice identified 10 criteria in the operative report that most frequently contained incomplete or missing information that is required for reimbursement of services (Table 1). These deficiencies were identified by University Surgical Associates (USA) coders as the reasons for denial of insurance reimbursement or delay of reimbursement. The deficiencies were then ranked in order of frequency based on the collective impressions of USA coders and used as evaluation criteria to audit USA operative notes as billing documents. The operative notes of 39 surgeons were reviewed for an average of 10 operative notes per surgeon (range, 5 to 15 operative notes). A higher number of operative notes were evaluated when procedures tended to be minimal and simplistic. Conversely, a smaller number of operative notes were audited when the procedures tended to be multisectioned and complex. Operative notes of elective procedures were reviewed. There were no emergency operations included in this study. Surgical disciplines included general surgery, otolaryngology, plastic and reconstructive surgery, surgical oncology, and urology. The majority of resident operative notes were dictated by senior (PG4 or PG5) surgical residents with only a small proportion dictated by more junior residents.
Results
A total of 550 operative notes were audited from January to February 2003. Seventy-six per cent (420/ 550) of the operative notes contained one or more of the audited criteria deficiencies. No deficiencies were identified in the remaining 24 per cent (130/550) of the audited operative notes. Thirty-nine per cent of operative notes were dictated by faculty surgeons, and 29 per cent of those contained no deficiencies. Of the 61 per cent of operative notes dictated by surgical residents, only 20 per cent contained no deficiencies.
The proportion of deficiencies in the operative notes occurred uniformly across the different surgical disciplines and between individual surgeons. There were no subsets of surgeons or specific surgical disciplines responsible for a disproportionately large number of deficiencies. This observation was consistent for both faculty-dictated operative notes and for resident-dictated operative notes. There were qualitative differences in deficiencies comparing the different surgical disciplines. For example, surgical oncology had the highest number of deficiencies related to the size of excised lesions, whereas plastic surgery experienced a higher proportion of deficiencies related to the length of repaired lacerations. The three most frequently occurring operative note deficiencies (description of the operative procedure, a clear explanation of the indications for the procedure, and the timeliness of the dictation of the operative note) occurred uniformly across the different surgical disciplines and between individual surgeons.
Quantitatively, the three most frequent deficiencies were incomplete description of all operative procedures performed, inadequate indications for the procedure, and only 45 per cent of the operative notes dictated with 24 hours of the procedure (Table 2). Other deficiencies appeared in a higher percentage but in a smaller number of operative notes. For example, chronic or acute diagnosis in 22 patients was not noted in 19 (86%) of the operative notes. Of 164 patients undergoing an operative procedure that was considered difficult, the reason for the increased degree of difficulty was not given in 100 (61%) of the operative notes. In 194 excisions, the size was not identified in 102 (53%). The size of lacerations repaired was not indicated in 61 per cent of the operative notes. In 34 per cent of patients undergoing a unilateral surgical procedure, the side of the, body was not indicated. In 47 planned or staged procedures, such as colostomy closure following a colon resection with protective colostomy, these details were not included in 64 per cent of operative notes. Other deficiencies shown in Table 2 represent simple, straightforward examples of appropriate documentation that should be included in an operative report.
Comparison of faculty-dictated operative notes to resident-dictated operative notes shows considerable variability in the frequency of deficiencies (Table 3). In only three instances did the operative notes of the residents contain fewer deficiencies than those dictated by faculty. Eighty-six per cent of faculty-dictated operative notes did not state a specific reason why a procedure was more difficult compared to 43 per cent of resident-dictated operative notes. In patients with acute or chronic disease, this condition was not specifically identified in 90 per cent of faculty-dictated operative notes compared to 83 per cent of residentdictated operative notes. Only 28 per cent of faculty dictated operative notes within 24 hours compared to 56 per cent of resident-dictated operative notes. In all other categories, there was a higher percentage of deficiencies in resident-dictated operative notes versus faculty-dictated notes.
Our professional coders estimated that the 550 operative notes reviewed for this audit represented $1,700,000 in charges. In turn, the 76 per cent of operative notes that required further justification represented just under $1,300,000 dollars in charges for which reimbursement was delayed.
Discussion
The majority (76%) of operative notes audited using the 10 deficiency criteria identified by USA professional coders contained one or more audit criteria deficiencies. The importance of dictating an operative note without deficiencies, from a billing standpoint, cannot be overemphasized, especially in the current economic environment in which the cost of practice continues to increase in the face of flat or decreasing reimbursement. The economic consequences of an operative note containing deficiencies include denial of payment or delayed payment for the service provided. In either case, an additional practice cost is incurred by the necessity of additional employee activity to address the circumstances. Medical assistants, filing clerks, and administrative personnel may spend considerable time sorting through charts, pathology reports, and office notes in an attempt to find appropriate information to either resubmit a charge or provide information to support an appeal. These expenses and inefficiencies are avoidable because the information can be provided in an appropriate manner by the surgeon in the operative note.
In this multispecialty academic surgical practice, more than 60 per cent of operative notes were dictated by residents. More deficiencies were found in operative notes dictated by surgical residents (80%) compared to operative notes dictated by surgical faculty (71%). In either case, the rate of deficiencies is unacceptably high, underlining the need for training both faculty and residents in providing appropriate material in the operative report to facilitate the billing process.
Listing all components of a surgical procedure is obviously not an issue in simple hernia repair or appendectomy, but it becomes increasingly important as the operative procedure becomes more complex with more components. If wide excision of a breast malignancy is combined with sentinal node sampling, each of the specific steps in the sentinal node sampling process should be clearly identified and listed in the initial description of the operative note and then described in more detail in the body of the operative report. A multitude of examples can be constructed specific for each surgical specialty. The wisest approach to this issue involves direct contact with coding personnel and advice on which specific components of the surgical procedure should be identified and in which manner in the operative note.
Forty-nine per cent of operative notes audited did not have an adequate description of the indications for the procedure. The indications section of operative notes often contain irrelevant data. The dictating surgeon needs to focus on the relationship between the procedure itself and the specific indications and attempt to avoid wandering commentaries on disease processes and other nonrelevant data.3
Only 45 per cent of operative notes were dictated within 24 hours of the procedure. It was remarkable to note that 18 per cent of audited operative notes were dictated more than 20 days after the procedure. The disadvantages of delayed dictation are obvious and include inability to remember the specific components of the procedure and important details of the technical aspects of various components. It is especially worrisome from a medico-legal standpoint to have an operative note in which the date of the procedure is considerably at variance with the date of dictation.
Most of the 10 criteria (Table 1) missing in these reports represent simple, straightforward appropriate documentation, such as the identification of the site and size and depth of an excised lesion (criteria 3) or the measurement of a sutured laceration (criteria 4). In both situations, reimbursement is increased with bigger lesions, longer lacerations, and more complex closures. Similarly, more difficult surgical procedures, when properly documented, can be recognized by coding modifiers and result in higher reimbursement (criteria 2). If the operative note does not identify a more difficult procedure with some specifics, reimbursement may either be denied or delayed. The identification of the side of the body on which a procedure was performed is also obvious. Remarkably, in 34 percent of operative notes audited, the side of the body was either not indicated or was inconsistent throughout the operative report.
If a procedure is staged intentionally (a colon resection with protective colostomy requiring a colostomy closure at some later date), this documentation needs to be explicitly included in the operative report in order to avoid denial of reimbursement for the later colostomy if it is conducted during the global period.
In the dictation of an operative note for billing documentation, a focus adjustment should be made by either the surgeon or the resident. Most notably, the purpose of the operative report is to create a record of patient care activity that is understandable to another health care professional (physician, nurse, allied health care professional) or an attorney. As a billing document, the dictating surgeon needs to recognize that the operative note will be evaluated at initial submission by an individual with a high school degree or perhaps a nurse employed by the insurance company responsible for the patient's health care coverage.2 At the appeals level, review of an operative report could be performed by a registered nurse or by a physician. The physician would not necessarily be a surgeon. It is entirely possible that the decision to reimburse for a surgical procedure at an appeals level could be made by an internist or pediatrician or some other nonsurgical specialist. Recognizing the components of this review and appeals process is an important stimulus to the surgeon to provide information in the operative note that will allow a professional in a nonsurgical specialty, and perhaps even a professional in a nonmedical status, to make an appropriate decision.
For health insurance companies, reimbursement for medical and surgical services is a game of "catch me if you can."11 Claim adjusters work for the insurance companies. Delay or denial of reimbursement claims allows the insurance companies to keep the money that would be paid for these services. If an operative note is inadequate in terms of documentation for billing purposes, the bottom line and cash flow of the insurance company benefits. Documentation in an operative note needs to correspond to the current procedural terminology (CPT) and/or ICD9 codes. The best method of achieving this is frequent communication and/or training by a professional coder. The operative note needs to be understandable to individuals who are less familiar with medical and surgical terminology than the surgeon. The considerable array of non-health care providers who may review an operative note includes receptionists, billing consultants, office managers, filing clerks, hospital administrative personnel, and insurance claims adjusters.2 If an operative note is confusing or if the terminology is so esoteric and complex that claims adjusters cannot understand it, the claim for payment will simply be either delayed or denied. The importance of the operative note has changed. In the days of Halstead and Gushing, the operative report was a record of patient care activity and often of historical events.3, 12 Today, it serves multiple functions and crosses many boundaries.
Conclusion
The operative note represents the most important document for the justification of reimbursement for surgical services provided. Surgeons of all specialties should reassess the operative note as a billing document and provide the information necessary to expedite reimbursement. Though the economic consequences of an inadequate operative note from a billing standpoint are difficult to quantify, they clearly represent an unnecessary and avoidable practice operational cost. The most efficient and direct method of providing necessary information in the operative note as a billing document is to have it included in the dictation by the operating surgeon.
The operative notes dictated by both faculty and residents contain a high portion of audit criteria deficiencies. Though faculty operative notes contain fewer deficiencies than resident operative notes, both represent a significant failure to produce high-quality operative reports. Both faculty and residents need specific instruction in providing the needed information in the operative note to facilitate the billing process. This is best accomplished by training by professional coders either individually or collectively.
Last, most of the information needed in the operative note for billing purposes is simple, straightforward data that is equally important documentation from the medical, medico-legal, and scientific standpoints. This is not an arduous, complicated process but simply represents an awareness of the importance of some very fundamental data, such as which side of the body was involved, the location of a lesion excised, the length of a laceration sutured, and so forth.
DISCUSSION
I. WILLIAM BROWDER, M.D. (Johnson City, TN): I congratulate the authors for focusing on an aspect of academic surgery that is increasingly important to the financial future of departments of surgery; namely, the operative note. Dr. Flynn has reviewed 550 operative notes with regard to their accuracy as a billing document-and not surprisingly, has found the majority (76%) to be deficient. Most common deficiencies were inadequate descriptions of the operative procedure, inadequate documentation of the indication for surgery, and delay more than 24 hours in dictating the operative note. While residents generally had more deficiencies than faculty, the difference was not significant, indicating problems with both groups of surgeons. As the authors point out, these results have a profound impact on financial and medico-legal issues in our surgical practice.
I have several methodological questions for Dr. Flynn.
1. The reviewed operative notes were dictated by 39 surgeons. What were the average number of deficiencies per surgeon? Was it possible that a small subset of surgeons were responsible for the majority of the problem?
2. Do you have a breakdown of the 550 procedures dictated as to whether they were emergency versus elective, complex versus simple? These factors may have counted for lapses in the operative note as well as delay in dictation.
3. Do you know the level of residents involved in each of the dictations? Resident inexperience might well have contributed to deficiencies in the note.
4. Do you have any estimate of the total dollar amount of reimbursement affected by the findings in your study?
Perhaps the most disturbing result of this review is the delay beyond 24 hours in dictating the operative note. The delay obviously has serious financial and legal consequences. We have struggled with this problem at our institution as you have. Many of our faculty insist on dictating their own operative note-potentially depriving the resident of what I believe is an important educational experience, that of dictating their own operative note. Some faculty have been comfortable with both a faculty and resident operative note on the same chart. Obviously, this practice could have some medico-legal impact as well, especially if the notes conflicted. What specific things have you done at Louisville to improve this delay in operative dictation?
Finally, these data are meaningful in so far as they lead to change in behavior and improvement in the operative note. What efforts have you made to educate your surgeons, and have subsequent audits shown a decrease in the deficiencies?
Again, I want to commend Dr. Flynn on addressing an important aspect of our surgical practice, one that is critical to our financial well-being in this new surgical era.
RICHARD D. STAHL, M.D. (Birmingham, AL): Who does the coding? I think that is important. The operative note is dictated by the surgeon or by the resident or someone who is doing the case, but I have always done my own coding with the belief that coding impacts me more than it impacts anybody else. Learning to code may require taking a coding course, but after learning, it doesn't take very long. In doing that, you also have some education for the residents in learning how to code. We did not have any of that and I took some courses after residency and it has been very helpful. Who does the coding: the surgeon or does office personnel do that? My recommendation would be the surgeon does his own coding.
RALEIGH B. KENT III, M.D. (Birmingham, AL): No one can argue about the importance of a succinct and accurate operative note. Initially, the medical record was meant for doctors to communicate with each other, but now it reflects other things other than medical care. second, I would ask who is doing the billing at Louisville? No one can make that charge and that code more accurate than the operating surgeon. I would encourage all of you to be familiar with the CPT book. If you are in an institution where you have a billing clerk who doesn't even know the surgeon, you're not going to get as accurate a billing and you are also going to run into problems with compliance issues.
JOHN B. HANKS, M.D. (Charlottesville, VA): Surgeons need to get to get familiar with the CPT code in terms of compliance issues and billing. We've really gotten into a system that is just dictating your own CPT code on the operative note. It is important to dictate the operative note so that it justifies the correct CPT code. About 10 years ago, none of us liked doing this when we started emphasizing CPT codes. We instituted a fine system for the surgeons, in terms of delinquent operative notes and so now with the electronic system, we all know after 24 hours from the time of surgery when the operative notes are due. A little fine goes a long way. Our compliance for 24-hour operative notes went from about 40 or 50 up to 99 per cent. We no longer really have a problem with that.
MICHAEL B. FLYNN, M.D. (Louisville, KY): I appreciate all of the discussion and I hope that I can answer your questions in a satisfactory manner.
Response to Dr. Browder's questions:
1. While we did not specifically audit the number of deficiencies per the number of surgeons, it was the impression of the coders who conducted the audit that the number of deficiencies was evenly spread out throughout the 39 surgeons and that it was not possible that a small set of surgeons were responsible for the majority of these deficiencies.
2. all of these procedures were elective, roughly 65 per cent were complex, multicomponent procedures versus roughly 35 per cent being simple, single component procedures. The issue of delay in dictation of operative notes is multifactorial. It is mostly a matter of the resident or the faculty member simply not getting this done in a timely manner.
3. The majority of resident dictations were carried out by senior PGY-4 or 5 residents.
4. The total of 550 operative notes represents 1.7 million dollars in charges with the 76 per cent representing 1.3 million dollars in charges for which reimbursement was delayed for varying periods of time in order to provide further information.
5. A hospital compliance requirement that operative notes are dictated within 24 hours has addressed the issue of operative note dictation. It will be interesting to see the effect of this when we conduct a re-audit.
6. From the standpoint of educational efforts, this topic has been presented by the coauthor and myself at two resident conferences and a number of less structured resident teaching opportunities. A detailed report was mailed to each surgery department faculty member. This report was presented in detail to the executive committee and the board of directors of the practice group and a presentation was made at a local surgical society, which includes both surgical faculty and private surgeons.
Response to Dr. Stahl: Coding is carried out both by faculty surgeons and staff in the coding section. We have encouraged faculty members to do their own coding and more are doing it than in the past. At this point in time, some kind of enforcement measure has not been instituted. If the professional coders have a good-quality operative note with the appropriate information regarding diagnostic coding, they will initiate billing. I agree that all surgeons should do their own coding.
Response to Dr. Raleigh B. Kent: Our professional coders do the billing. If the surgeon submits the code, they doublecheck it with the available documentation and it is then processed electronically. If a surgeon has not submitted a code for a procedure and the documentation for procedure and diagnostic codes are available, they will submit charges. This is done electronically except when hardcopy justification such as an operative note has to accompany the charge.
Response to Dr. John B. Hanks: I agree with Dr. Hanks regarding the value of penalty process for delay in documentation or coding. Unfortunately, we have not yet instituted something of this nature.
Lastly, I would like to thank the discussants for their comments, their questions, and thank the society for the privilege of presenting this study.
[Reference]
REFERENCES
1. Vaught MS. Breaking the codes: understanding the type of documentation payors want-and providing it-is the key to a smooth reimbursement process. Orthopedic Tech Review [online serial]. 1999;1 (Oct/Nov). Available at: hllp://www. orthopedictechrcview.com/backissues.htm.
2. Painter MN. What surgeons should know about operative reports and reimbursement. Bull Am Coll Surg 1994;79:6-8.
3. Goldwyn RM. The operative note [editorial]. Plast Reconstr Surg 1982;69:676-7.
4. Pettinari C, Weaver DW. Learning to dictate and report: a case study of operative report evolution during residency training. Top Health Record Manage 1987;8:49-56.
5. Bateman ND, Carney AS, Gibbin KP. An audit of the quality of operation notes in an otolaryngology unit. JR Coll Surg Edinb 1999;44:94-5.
6. Stanley-Brown EG. How to dictate operative notes. Resident & Staff Physician 1983;(Feb): 109-10.
7. University Relations of the University of Iowa. [Compiled by Epstein S.] Instructional improvement award to Anil K. Sood to teach key components of operative note dictations to residents and medical students. FYI Faculty and Staff News [online serial]. 2002;39. Available at: http://www.uiowa.edu/~fyi/ issues2001_v39/03082002fyi/improvement.html.
8. McLeod L. Simple forms make post-operative notes easy to complete [letter]. HCPro Inc. and the Health Information Management Supersite. Available at: hltp:://www.himinfo.coin/news/ himconnection/himconn-arc.cfm?contcnt_ID-21570.
9. Ingenix. Coding lab: coding from the operative report 2004. Salt Lake City, UT: Ingenix Publishing Group/St. Anthony Publishing/Medicode, 2004.
10. Regents of the University of Michigan, Department of Surgery and MCIT. STAR: Surgery Tracking and Activity Reporting 1997 [workflow and messaging database!. Available at: http:// www.med.umich.edu/surg/star/hlml/star_docurncnt.html.
11. Flynn MB. Where does the money go or who gets to keep the money? Louisville Medicine 2003;51:277-9.
12. Gushing H. Operative note, October 1, 1926, in Peter Bent Brigham Hospital records, Boston [as cited and quoted in Goldwyn RM. The operative note. Plast Reconstr Surg 1982;69:676-7].
[Author Affiliation]
MICHAEL B. FLYNN, M.D., DORA A. ALLEN, C.P.C.
From the Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
[Author Affiliation]
Presented at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Atlanta, Georgia, January 31-February 3, 2004.
Address correspondence and reprint requests to Michael B. Flynn, M.D., Department of Surgery, University of Louisville, School of Medicine, Louisville, KY 40292.
The Operative Note as Billing Documentation: A Preliminary Report/DISCUSSIONCertified professional coders from a multispecialty academic surgical practice used operative notes to identify 10 of the most common deficiencies for reimbursement of services. These 10 deficiencies were then used as evaluation criteria to audit the operative notes used as billing documentation. Twenty-four per cent of operative notes contained no deficiencies, whereas the remaining 76 per cent contained one or more audit criteria deficiencies. The three most common deficiencies identified included an incomplete description of all surgical procedures performed (56%), an inadequate description of the indications for procedures (49%), and only 45 per cent of the operative notes were dictated within 24 hours of the procedure. Thirty-nine per cent were dictated by faculty surgeons, whereas 61 per cent were dictated by surgical residents. Twenty-nine per cent of the operative notes that were dictated by faculty surgeons contained no deficiencies as compared with 20 per cent of the operative notes that were dictated by surgical residents. For a multispecialty academic surgical practice, the operative note is the document of justification for 75 per cent of revenue generated. We conclude that 1) the operative note represents the most important document for justification of reimbursement for surgical services, 2) surgeons should reassess the operative note as a billing document and provide the information necessary to expedite reimbursement, 3) surgical residents should be instructed in the details of an operative report as a billing document, and 4) most of the information needed in the operative note for billing purposes is simple and straightforward data that is important not only for reimbursement but also from a medico-legal and medical records standpoint.
THE OPERATIVE REPORT serves a variety of functions. Most fundamentally, it is a record of patient care activity and an important component of both hospital and office records. It may be an educational document for resident training and may be of some scientific value for research purposes. Medico-legally, the operative note is a major factor in litigation related to surgery. The operative note provides documentation for billing to insurance companies for reimbursement of surgical services provided.1,2 The extent to which the operative note represents justification for revenue varies with surgical specialities, from 90 per cent in general surgery and plastic surgery to 45 per cent to 50 per cent for otolaryngology and urology.
In our recent review of the surgical literature in Medline and on the Internet, there was surprisingly little data related to operative notes.1-10 This current report is to evaluate the use of operative notes as a billing document in a multispecialty academic surgical practice.
Materials and Methods
Certified professional coders from a multispecialty academic surgical practice identified 10 criteria in the operative report that most frequently contained incomplete or missing information that is required for reimbursement of services (Table 1). These deficiencies were identified by University Surgical Associates (USA) coders as the reasons for denial of insurance reimbursement or delay of reimbursement. The deficiencies were then ranked in order of frequency based on the collective impressions of USA coders and used as evaluation criteria to audit USA operative notes as billing documents. The operative notes of 39 surgeons were reviewed for an average of 10 operative notes per surgeon (range, 5 to 15 operative notes). A higher number of operative notes were evaluated when procedures tended to be minimal and simplistic. Conversely, a smaller number of operative notes were audited when the procedures tended to be multisectioned and complex. Operative notes of elective procedures were reviewed. There were no emergency operations included in this study. Surgical disciplines included general surgery, otolaryngology, plastic and reconstructive surgery, surgical oncology, and urology. The majority of resident operative notes were dictated by senior (PG4 or PG5) surgical residents with only a small proportion dictated by more junior residents.
Results
A total of 550 operative notes were audited from January to February 2003. Seventy-six per cent (420/ 550) of the operative notes contained one or more of the audited criteria deficiencies. No deficiencies were identified in the remaining 24 per cent (130/550) of the audited operative notes. Thirty-nine per cent of operative notes were dictated by faculty surgeons, and 29 per cent of those contained no deficiencies. Of the 61 per cent of operative notes dictated by surgical residents, only 20 per cent contained no deficiencies.
The proportion of deficiencies in the operative notes occurred uniformly across the different surgical disciplines and between individual surgeons. There were no subsets of surgeons or specific surgical disciplines responsible for a disproportionately large number of deficiencies. This observation was consistent for both faculty-dictated operative notes and for resident-dictated operative notes. There were qualitative differences in deficiencies comparing the different surgical disciplines. For example, surgical oncology had the highest number of deficiencies related to the size of excised lesions, whereas plastic surgery experienced a higher proportion of deficiencies related to the length of repaired lacerations. The three most frequently occurring operative note deficiencies (description of the operative procedure, a clear explanation of the indications for the procedure, and the timeliness of the dictation of the operative note) occurred uniformly across the different surgical disciplines and between individual surgeons.
Quantitatively, the three most frequent deficiencies were incomplete description of all operative procedures performed, inadequate indications for the procedure, and only 45 per cent of the operative notes dictated with 24 hours of the procedure (Table 2). Other deficiencies appeared in a higher percentage but in a smaller number of operative notes. For example, chronic or acute diagnosis in 22 patients was not noted in 19 (86%) of the operative notes. Of 164 patients undergoing an operative procedure that was considered difficult, the reason for the increased degree of difficulty was not given in 100 (61%) of the operative notes. In 194 excisions, the size was not identified in 102 (53%). The size of lacerations repaired was not indicated in 61 per cent of the operative notes. In 34 per cent of patients undergoing a unilateral surgical procedure, the side of the, body was not indicated. In 47 planned or staged procedures, such as colostomy closure following a colon resection with protective colostomy, these details were not included in 64 per cent of operative notes. Other deficiencies shown in Table 2 represent simple, straightforward examples of appropriate documentation that should be included in an operative report.
Comparison of faculty-dictated operative notes to resident-dictated operative notes shows considerable variability in the frequency of deficiencies (Table 3). In only three instances did the operative notes of the residents contain fewer deficiencies than those dictated by faculty. Eighty-six per cent of faculty-dictated operative notes did not state a specific reason why a procedure was more difficult compared to 43 per cent of resident-dictated operative notes. In patients with acute or chronic disease, this condition was not specifically identified in 90 per cent of faculty-dictated operative notes compared to 83 per cent of residentdictated operative notes. Only 28 per cent of faculty dictated operative notes within 24 hours compared to 56 per cent of resident-dictated operative notes. In all other categories, there was a higher percentage of deficiencies in resident-dictated operative notes versus faculty-dictated notes.
Our professional coders estimated that the 550 operative notes reviewed for this audit represented $1,700,000 in charges. In turn, the 76 per cent of operative notes that required further justification represented just under $1,300,000 dollars in charges for which reimbursement was delayed.
Discussion
The majority (76%) of operative notes audited using the 10 deficiency criteria identified by USA professional coders contained one or more audit criteria deficiencies. The importance of dictating an operative note without deficiencies, from a billing standpoint, cannot be overemphasized, especially in the current economic environment in which the cost of practice continues to increase in the face of flat or decreasing reimbursement. The economic consequences of an operative note containing deficiencies include denial of payment or delayed payment for the service provided. In either case, an additional practice cost is incurred by the necessity of additional employee activity to address the circumstances. Medical assistants, filing clerks, and administrative personnel may spend considerable time sorting through charts, pathology reports, and office notes in an attempt to find appropriate information to either resubmit a charge or provide information to support an appeal. These expenses and inefficiencies are avoidable because the information can be provided in an appropriate manner by the surgeon in the operative note.
In this multispecialty academic surgical practice, more than 60 per cent of operative notes were dictated by residents. More deficiencies were found in operative notes dictated by surgical residents (80%) compared to operative notes dictated by surgical faculty (71%). In either case, the rate of deficiencies is unacceptably high, underlining the need for training both faculty and residents in providing appropriate material in the operative report to facilitate the billing process.
Listing all components of a surgical procedure is obviously not an issue in simple hernia repair or appendectomy, but it becomes increasingly important as the operative procedure becomes more complex with more components. If wide excision of a breast malignancy is combined with sentinal node sampling, each of the specific steps in the sentinal node sampling process should be clearly identified and listed in the initial description of the operative note and then described in more detail in the body of the operative report. A multitude of examples can be constructed specific for each surgical specialty. The wisest approach to this issue involves direct contact with coding personnel and advice on which specific components of the surgical procedure should be identified and in which manner in the operative note.
Forty-nine per cent of operative notes audited did not have an adequate description of the indications for the procedure. The indications section of operative notes often contain irrelevant data. The dictating surgeon needs to focus on the relationship between the procedure itself and the specific indications and attempt to avoid wandering commentaries on disease processes and other nonrelevant data.3
Only 45 per cent of operative notes were dictated within 24 hours of the procedure. It was remarkable to note that 18 per cent of audited operative notes were dictated more than 20 days after the procedure. The disadvantages of delayed dictation are obvious and include inability to remember the specific components of the procedure and important details of the technical aspects of various components. It is especially worrisome from a medico-legal standpoint to have an operative note in which the date of the procedure is considerably at variance with the date of dictation.
Most of the 10 criteria (Table 1) missing in these reports represent simple, straightforward appropriate documentation, such as the identification of the site and size and depth of an excised lesion (criteria 3) or the measurement of a sutured laceration (criteria 4). In both situations, reimbursement is increased with bigger lesions, longer lacerations, and more complex closures. Similarly, more difficult surgical procedures, when properly documented, can be recognized by coding modifiers and result in higher reimbursement (criteria 2). If the operative note does not identify a more difficult procedure with some specifics, reimbursement may either be denied or delayed. The identification of the side of the body on which a procedure was performed is also obvious. Remarkably, in 34 percent of operative notes audited, the side of the body was either not indicated or was inconsistent throughout the operative report.
If a procedure is staged intentionally (a colon resection with protective colostomy requiring a colostomy closure at some later date), this documentation needs to be explicitly included in the operative report in order to avoid denial of reimbursement for the later colostomy if it is conducted during the global period.
In the dictation of an operative note for billing documentation, a focus adjustment should be made by either the surgeon or the resident. Most notably, the purpose of the operative report is to create a record of patient care activity that is understandable to another health care professional (physician, nurse, allied health care professional) or an attorney. As a billing document, the dictating surgeon needs to recognize that the operative note will be evaluated at initial submission by an individual with a high school degree or perhaps a nurse employed by the insurance company responsible for the patient's health care coverage.2 At the appeals level, review of an operative report could be performed by a registered nurse or by a physician. The physician would not necessarily be a surgeon. It is entirely possible that the decision to reimburse for a surgical procedure at an appeals level could be made by an internist or pediatrician or some other nonsurgical specialist. Recognizing the components of this review and appeals process is an important stimulus to the surgeon to provide information in the operative note that will allow a professional in a nonsurgical specialty, and perhaps even a professional in a nonmedical status, to make an appropriate decision.
For health insurance companies, reimbursement for medical and surgical services is a game of "catch me if you can."11 Claim adjusters work for the insurance companies. Delay or denial of reimbursement claims allows the insurance companies to keep the money that would be paid for these services. If an operative note is inadequate in terms of documentation for billing purposes, the bottom line and cash flow of the insurance company benefits. Documentation in an operative note needs to correspond to the current procedural terminology (CPT) and/or ICD9 codes. The best method of achieving this is frequent communication and/or training by a professional coder. The operative note needs to be understandable to individuals who are less familiar with medical and surgical terminology than the surgeon. The considerable array of non-health care providers who may review an operative note includes receptionists, billing consultants, office managers, filing clerks, hospital administrative personnel, and insurance claims adjusters.2 If an operative note is confusing or if the terminology is so esoteric and complex that claims adjusters cannot understand it, the claim for payment will simply be either delayed or denied. The importance of the operative note has changed. In the days of Halstead and Gushing, the operative report was a record of patient care activity and often of historical events.3, 12 Today, it serves multiple functions and crosses many boundaries.
Conclusion
The operative note represents the most important document for the justification of reimbursement for surgical services provided. Surgeons of all specialties should reassess the operative note as a billing document and provide the information necessary to expedite reimbursement. Though the economic consequences of an inadequate operative note from a billing standpoint are difficult to quantify, they clearly represent an unnecessary and avoidable practice operational cost. The most efficient and direct method of providing necessary information in the operative note as a billing document is to have it included in the dictation by the operating surgeon.
The operative notes dictated by both faculty and residents contain a high portion of audit criteria deficiencies. Though faculty operative notes contain fewer deficiencies than resident operative notes, both represent a significant failure to produce high-quality operative reports. Both faculty and residents need specific instruction in providing the needed information in the operative note to facilitate the billing process. This is best accomplished by training by professional coders either individually or collectively.
Last, most of the information needed in the operative note for billing purposes is simple, straightforward data that is equally important documentation from the medical, medico-legal, and scientific standpoints. This is not an arduous, complicated process but simply represents an awareness of the importance of some very fundamental data, such as which side of the body was involved, the location of a lesion excised, the length of a laceration sutured, and so forth.
DISCUSSION
I. WILLIAM BROWDER, M.D. (Johnson City, TN): I congratulate the authors for focusing on an aspect of academic surgery that is increasingly important to the financial future of departments of surgery; namely, the operative note. Dr. Flynn has reviewed 550 operative notes with regard to their accuracy as a billing document-and not surprisingly, has found the majority (76%) to be deficient. Most common deficiencies were inadequate descriptions of the operative procedure, inadequate documentation of the indication for surgery, and delay more than 24 hours in dictating the operative note. While residents generally had more deficiencies than faculty, the difference was not significant, indicating problems with both groups of surgeons. As the authors point out, these results have a profound impact on financial and medico-legal issues in our surgical practice.
I have several methodological questions for Dr. Flynn.
1. The reviewed operative notes were dictated by 39 surgeons. What were the average number of deficiencies per surgeon? Was it possible that a small subset of surgeons were responsible for the majority of the problem?
2. Do you have a breakdown of the 550 procedures dictated as to whether they were emergency versus elective, complex versus simple? These factors may have counted for lapses in the operative note as well as delay in dictation.
3. Do you know the level of residents involved in each of the dictations? Resident inexperience might well have contributed to deficiencies in the note.
4. Do you have any estimate of the total dollar amount of reimbursement affected by the findings in your study?
Perhaps the most disturbing result of this review is the delay beyond 24 hours in dictating the operative note. The delay obviously has serious financial and legal consequences. We have struggled with this problem at our institution as you have. Many of our faculty insist on dictating their own operative note-potentially depriving the resident of what I believe is an important educational experience, that of dictating their own operative note. Some faculty have been comfortable with both a faculty and resident operative note on the same chart. Obviously, this practice could have some medico-legal impact as well, especially if the notes conflicted. What specific things have you done at Louisville to improve this delay in operative dictation?
Finally, these data are meaningful in so far as they lead to change in behavior and improvement in the operative note. What efforts have you made to educate your surgeons, and have subsequent audits shown a decrease in the deficiencies?
Again, I want to commend Dr. Flynn on addressing an important aspect of our surgical practice, one that is critical to our financial well-being in this new surgical era.
RICHARD D. STAHL, M.D. (Birmingham, AL): Who does the coding? I think that is important. The operative note is dictated by the surgeon or by the resident or someone who is doing the case, but I have always done my own coding with the belief that coding impacts me more than it impacts anybody else. Learning to code may require taking a coding course, but after learning, it doesn't take very long. In doing that, you also have some education for the residents in learning how to code. We did not have any of that and I took some courses after residency and it has been very helpful. Who does the coding: the surgeon or does office personnel do that? My recommendation would be the surgeon does his own coding.
RALEIGH B. KENT III, M.D. (Birmingham, AL): No one can argue about the importance of a succinct and accurate operative note. Initially, the medical record was meant for doctors to communicate with each other, but now it reflects other things other than medical care. second, I would ask who is doing the billing at Louisville? No one can make that charge and that code more accurate than the operating surgeon. I would encourage all of you to be familiar with the CPT book. If you are in an institution where you have a billing clerk who doesn't even know the surgeon, you're not going to get as accurate a billing and you are also going to run into problems with compliance issues.
JOHN B. HANKS, M.D. (Charlottesville, VA): Surgeons need to get to get familiar with the CPT code in terms of compliance issues and billing. We've really gotten into a system that is just dictating your own CPT code on the operative note. It is important to dictate the operative note so that it justifies the correct CPT code. About 10 years ago, none of us liked doing this when we started emphasizing CPT codes. We instituted a fine system for the surgeons, in terms of delinquent operative notes and so now with the electronic system, we all know after 24 hours from the time of surgery when the operative notes are due. A little fine goes a long way. Our compliance for 24-hour operative notes went from about 40 or 50 up to 99 per cent. We no longer really have a problem with that.
MICHAEL B. FLYNN, M.D. (Louisville, KY): I appreciate all of the discussion and I hope that I can answer your questions in a satisfactory manner.
Response to Dr. Browder's questions:
1. While we did not specifically audit the number of deficiencies per the number of surgeons, it was the impression of the coders who conducted the audit that the number of deficiencies was evenly spread out throughout the 39 surgeons and that it was not possible that a small set of surgeons were responsible for the majority of these deficiencies.
2. all of these procedures were elective, roughly 65 per cent were complex, multicomponent procedures versus roughly 35 per cent being simple, single component procedures. The issue of delay in dictation of operative notes is multifactorial. It is mostly a matter of the resident or the faculty member simply not getting this done in a timely manner.
3. The majority of resident dictations were carried out by senior PGY-4 or 5 residents.
4. The total of 550 operative notes represents 1.7 million dollars in charges with the 76 per cent representing 1.3 million dollars in charges for which reimbursement was delayed for varying periods of time in order to provide further information.
5. A hospital compliance requirement that operative notes are dictated within 24 hours has addressed the issue of operative note dictation. It will be interesting to see the effect of this when we conduct a re-audit.
6. From the standpoint of educational efforts, this topic has been presented by the coauthor and myself at two resident conferences and a number of less structured resident teaching opportunities. A detailed report was mailed to each surgery department faculty member. This report was presented in detail to the executive committee and the board of directors of the practice group and a presentation was made at a local surgical society, which includes both surgical faculty and private surgeons.
Response to Dr. Stahl: Coding is carried out both by faculty surgeons and staff in the coding section. We have encouraged faculty members to do their own coding and more are doing it than in the past. At this point in time, some kind of enforcement measure has not been instituted. If the professional coders have a good-quality operative note with the appropriate information regarding diagnostic coding, they will initiate billing. I agree that all surgeons should do their own coding.
Response to Dr. Raleigh B. Kent: Our professional coders do the billing. If the surgeon submits the code, they doublecheck it with the available documentation and it is then processed electronically. If a surgeon has not submitted a code for a procedure and the documentation for procedure and diagnostic codes are available, they will submit charges. This is done electronically except when hardcopy justification such as an operative note has to accompany the charge.
Response to Dr. John B. Hanks: I agree with Dr. Hanks regarding the value of penalty process for delay in documentation or coding. Unfortunately, we have not yet instituted something of this nature.
Lastly, I would like to thank the discussants for their comments, their questions, and thank the society for the privilege of presenting this study.
[Reference]
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[Author Affiliation]
MICHAEL B. FLYNN, M.D., DORA A. ALLEN, C.P.C.
From the Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
[Author Affiliation]
Presented at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Atlanta, Georgia, January 31-February 3, 2004.
Address correspondence and reprint requests to Michael B. Flynn, M.D., Department of Surgery, University of Louisville, School of Medicine, Louisville, KY 40292.
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